Damage Control Resuscitation Research Articles

Ten-year evolution of a massive transfusion protocol in a level 1 trauma centre: have outcomes improved?

BackgroundWe aimed to evaluate the evolution and implementation of the massive transfusion protocol (MTP) in an urban level 1 trauma centre. Most data on this topic comes from trauma centres with high exposure to life‐threatening haemorrhage. This study examines the effect of the introduction of an MTP in an Australian level 1 trauma centre.MethodsA retrospective study of prospectively collected data was performed over a 14‐year period. Three groups of trauma patients, who received more than 10 units of packed red blood cells (PRBC), were compared: a pre‐MTP group (2002–2006), an MTP‐I group (2006–2010) and an MTP‐II group (2010–2016) when the protocol was updated. Key outcomes were mortality, complications and number of blood products transfused.ResultsA total of 168 patients were included: 54 pre‐MTP patients were compared to 47 MTP‐I and 67 MTP‐II patients. In the MTP‐II group, fewer units of PRBC and platelets were administered within the first 24 h: 17 versus 14 (P = 0.01) and 12 versus 8 (P < 0.001), respectively. Less infections were noted in the MTP‐I group: 51.9% versus 31.9% (P = 0.04). No significant differences were found regarding mortality, ventilator days, intensive care unit and total hospital lengths of stay.ConclusionIntroduction of an MTP‐II in our level 1 civilian trauma centre significantly reduced the amount of PRBC and platelets used during damage control resuscitation. Introduction of the MTP did not directly impact survival or the incidence of complications. Nevertheless, this study reflects the complexity of real‐life medical care in a level 1 civilian trauma centre.

Minimizing Time to Plasma Administration and Fresh Frozen Plasma Waste: A Multimodal Approach to Improve Massive Transfusion at a Level 1 Trauma Center.

Massive transfusion protocols are part of damage control resuscitation for hemorrhaging trauma patients with the goal of returning the patient to hemodynamic stability. It is essential that patients receive blood products immediately and in the proper ratios. At our metropolitan Level 1 trauma center, we identified several challenges to deploying massive transfusion rapidly and within the recommended ratio guidelines. In 2016, we implemented a quality improvement project addressing 4 opportunities: fresh frozen plasma (FFP) bag breakage, plasma options, blood bank equipment, and multidisciplinary policy revision. Implementing packaging and shipping improvements, utilization of new products, and updating protocols have resulted in a 50% decrease in FFP bag breakage rates, a dramatic decrease in time for patients receiving massive transfusion to receive plasma products (mean time 3.5 min), and patients being administered the recommended ratio of blood products.

The use of prehospital blood products in the resuscitation of trauma patients: a review of prehospital transfusion practices and a description of our regional whole blood program in San Antonio, TX

BackgroundPrehospital management of the traumatically injured patient has evolved significantly since the organization of emergency medical services across the United States in the 1970s. Initially focusing on the utilization of crystalloid solutions to restore shed blood volume, robust military and civilian trauma experiences led to a modern day shift towards balanced blood component and ultimately whole blood use for immediate volume replacement. In addition, prehospital transfusion or remote damage control resuscitation (RDRC) has been widely adopted. This has led to point of injury resuscitation using blood products both in the United States and abroad.ObjectivesThis article will review the evolution of civilian and military prehospital resuscitation as well as the current practice of prehospital whole blood transfusion in the civilian trauma population in the United States. Additionally, we will provide an overview of our regional trauma system's use of whole blood with focus on the programme infrastructure, donor programme, product rotation schedule and logistical challenges. Finally, we provide three case report examples of the effective use of whole blood in our civilian emergency medical services (EMS) programs.

Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center.

Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center. The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011-2013) and trauma center (TC) (2014-2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality. Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80min, p = 0.022), time from admission to operation (125 vs. 112min, p = 0.010), time from admission to first treatment (119 vs. 99min, p = 0.004), and time from admission to first transfusion (70 vs. 52min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period. After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.

Combination therapy using fibrinogen γ-chain peptide-coated, ADP-encapsulated liposomes and hemoglobin vesicles for trauma-induced massive hemorrhage in thrombocytopenic rabbits.

We previously developed substitutes for red blood cells (RBCs) and platelets (PLTs) for transfusion. These substitutes included hemoglobin vesicles (HbVs) and fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV, H12)-coated, adenosine diphosphate (ADP)-encapsulated liposomes [H12-(ADP)-liposomes]. Here, we examined the efficacy of combination therapy using these substitutes instead of RBC and PLT transfusion in a rabbit model with trauma-induced massive hemorrhage with coagulopathy. Thrombocytopenia (PLT count approximately 40,000/μL) was induced in rabbits by repeated blood withdrawal and isovolemic transfusion with autologous RBCs. Thereafter, lethal hemorrhage was induced in rabbits by noncompressible penetrating liver injury. Subsequently, H12-(ADP)-liposomes with platelet-poor plasma (PPP), platelet-rich plasma (PRP), or PPP alone were administered to stop bleeding. Once achieving hemostasis, HbVs, allogenic RBCs, or 5% albumin were transfused into rabbits to rescue them from fatal anemia following massive hemorrhage. Administration of H12-(ADP)-liposomes/PPP as well as PRP (but not PPP) effectively stopped liver bleeding (100% hemostasis). The subsequent administration with HbVs as well as RBCs after hemostasis markedly rescued rabbits from fatal anemia (75% and 70% survivals for 24 hr, respectively). In contrast, 5% albumin administration rescued none of the rabbits. Combination therapy with H12-(ADP)-liposomes and HbVs may be effective for damage control resuscitation of trauma-induced massive hemorrhage.

Damage control resuscitation in children

Damage control resuscitation is a relatively new resuscitative strategy for patients with severe traumatic hemorrhage. This strategy consists of permissive hypotension and early balanced transfusion, and transfers the patients to subsequent surgery. There is growing evidence on harms of excessive fluids. Since 2013, survival benefit of massive transfusion protocol has been proven in adults. Despite insufficient evidence, pediatric massive transfusion protocols are widely used in North American trauma centers. This review focuses on the concept of damage control resuscitation, and summarizes the relevant pediatric evidence. Key Words: Blood Coagulation Disorders; Blood Transfusion; Child; Emergency Medicine; Hemostasis; Hypotension, Controlled; Resuscitation; Wounds and Injuries

Combat Vascular Trauma Management for the General Surgeon

This review focuses on the initial management and stabilization of complex vascular injuries for the general surgeon within the combat zone. Recent conflicts in Iraq, Afghanistan, and Syria demonstrate that general surgeons are responsible for the initial surgical management of combat-related vascular trauma in damage control scenarios. These injuries display a more complex injury pattern and often require different management strategies than seen in civilian trauma. Vascular trauma in combat settings is often accompanied by a multitude of life- and limb-threatening injuries. Definitive repair operations are often deferred for initial damage control surgery and resuscitation. Resultant strategies to restore perfusion and control bleeding are determined by the patient’s underlying physiology and frequently require the use of vascular shunts, ligation, primary anastomosis, or interposition grafting. While general surgeons in the combat zone are not typically responsible for definitive repair during initial damage control surgery, proper initial surgical management in the far-forward setting with an intimate understanding of future repair strategies remains critical aspects in assuring optimal definitive treatment.

Damage control resuscitation and surgery for indigenous combat casualties: a prospective observational study

IntroductionSpecialist units that assist indigenous forces (IF) in their strategic aims are supported by medical teams providing point of injury emergency care for casualties, including IF and civilians (Civ). We...

Contemporary Transfusion Science and Challenges.

Health care professionals must understand the impact of blood product transfusions and transfusion therapy procedures to ensure high-quality patient care, positive outcomes, and wise use of resources in blood management programs. Understanding transfusions of blood and blood products is also important because of the number of treatments performed, which affects individual patients and health care system resources. This article reviews research findings to acquaint health care professionals with the most successful protocols for blood, blood product, and coagulation factor transfusions. Damage control resuscitation in bleeding trauma patients, protocols for patients without trauma who are undergoing surgical procedures that place them at risk for excessive bleeding, and protocols for patients with sepsis are addressed. Emerging research continues to help guide mass transfusion treatments (restrictive vs liberal, balanced, and goal-directed treatment). Although available study results provide some guidance, questions remain. Additional research by health care professionals is needed.

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.

Alone and Sometimes Unafraid: Military Perspective on Forward Damage Control Resuscitation on the Modern Battlefield

The objective of this review is to describe the military experience and utilization of damage control resuscitation as well as explore future developments to push the best medicine far forward in the austere environment. The Global War on Terror has transitioned from mature combat theaters staged with rapid medical evacuation and robust medical facilities to more austere environments. Due to this transition, the military medical force has adopted the practice of sending providers and surgeons into forward deployed environments to provide Damage Control Resuscitation closer to the point of injury. This review focuses on the key tenets of Damage Control Resuscitation and its development. It also describes how various military units have adopted damage control resuscitation principles.

Characteristics of Prehospital Response to Terrorism: A systematic literature review

Background: Terrorism is increasingly the aetiology of mass casualty incidents. Improved prehospital response capability targeted to the unique characteristics of high threat incidents is an area of urgent focus. Gaps in current knowledge coupled with inconsistent reporting and difficulties in accessing data create difficult conditions for capability enhancement.&#x0D; Methods: A systematic literature review was conducted to describe the characteristics of prehospital response to terrorism from 2011 -2017. Papers were included if they described a prehospital response to a terrorist incident, were in English or translatable to English and full text was available.&#x0D; Results: 6115 records were located in the initial search of grey and published literature, with 71 retrieved for full text after screening of title and abstract. 23 papers were included in the final analysis, describing 6 separate terrorist attacks. The majority of literature was published by physicians, all were from Western countries with advanced Emergency Medical Services(EMS) and a standard reporting template was not identified. The level of evidence was low to very low. Themes of tactical triage, coordinated activation and response, use of damage control resuscitation and tactical casualty care were common throughout the papers.&#x0D; Conclusions: The paucity of high level evidence and systematic reporting of lessons learned in the prehospital terrorism response field requires a renewed push for access to data and the establishment of reporting systems that are inclusive of all responders.&#x0D; Keywords: Terrorism, Pre-hospital, Response, Tactical Emergency Casualty Care, Tactical Combat Casualty Care

Damage control resuscitation initiated in the prehospital and transport setting: A systems approach to increasing access to blood transfusion.

Damage control resuscitation initiated in the prehospital and transport setting: A systems approach to increasing access to blood transfusion.

Progress on combat damage control resuscitation/surgery and its application in the Chinese People's Liberation Army.

Damage control resuscitation (DCR) and damage control surgery (DCS) has now been developed as a well-established standard of care for severely injured civilian patients worldwide. On the other hand, the application of combat DCR/DCS has saved the lives of thousands of severely injured casualties in several wars during the last two decades. This article describes the great progress on DCR/DCS in the last two decades and its application in the Chinese People's Liberation Army (PLA). The main development of the advanced theories of combat DCR/DCS including the global integration of DCR/DCS, application of remote battlefield DCR, balanced hemostatic resuscitation in combat hospitals and enhancement of en route DCR. There are two key factors that determine the feasibility of combat DCR: one is the availability of resources and supplies to implement the advanced theories of combat DCR/DCS, the other is the availability of qualified personnel who master the skills needed for the implementation of DCR/DCS. In the PLA, the advanced theories of combat DCR/DCS have now been widely accepted, and some of related advanced products, such as fresh-frozen plasma, packed red blood cells, and platelets, have been available in Level III medical facilities. In conclusion, great progress in combat DCR/DCS has been achieved in recent years, and the Chinese PLA is keeping good pace with this development, although there is still room for improvement.

Damage Control Resuscitation en el paciente traumático

Haemorrhagic shock is one of the main causes of mortality in severe polytrauma patients. To increase the survival rates, a combined strategy of treatment known as Damage Control has been developed.The aims of this article are to analyse the actual concept of Damage Control Resuscitation and its three treatment levels, describe the best transfusion strategy, and approach the acute coagulopathy of the traumatic patient as an entity. The potential changes of this therapeutic strategy over the coming years are also described.

Selective aortic arch perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of noncompressible torso hemorrhage.

Hemorrhage-induced traumatic cardiac arrest (HiTCA) has a dismal survival rate. Previous studies demonstrated selective aortic arch perfusion (SAAP) with fresh whole blood (FWB) improved the rate of return of spontaneous circulation (ROSC) after HiTCA, compared with resuscitative endovascular balloon occlusion of the aorta and cardiopulmonary resuscitation (CPR). Hemoglobin-based oxygen carriers, such as hemoglobin-based oxygen carrier (HBOC)-201, may alleviate the logistical constraints of using FWB in a prehospital setting. It is unknown whether SAAP with HBOC-201 is equivalent in efficacy to FWB, whether conversion from SAAP to extracorporeal life support (ECLS) is feasible, and whether physiologic derangement post-SAAP therapy is reversible. Twenty-six swine (79 ± 4 kg) were anesthetized and underwent HiTCA which was induced via liver injury and controlled hemorrhage. Following arrest, swine were randomly allocated to resuscitation using SAAP with FWB (n = 12) or HBOC-201 (n = 14). After SAAP was initiated, animals were monitored for a 20-minute prehospital period prior to a 40-minute damage control surgery and resuscitation phase, followed by 260 minutes of critical care. Primary outcomes included rate of ROSC, survival, conversion to ECLS, and correction of physiology. Baseline physiologic measurements were similar between groups. ROSC was achieved in 100% of the FWB animals and 86% of the HBOC-201 animals (p = 0.483). Survival (t = 320 minutes) was 92% (11/12) in the FWB group and 67% (8/12) in the HBOC-201 group (p = 0.120). Conversion to ECLS was successful in 100% of both groups. Lactate peaked at 80 minutes in both groups, and significantly improved by the end of the experiment in the HBOC-201 group (p = 0.001) but not in the FWB group (p = 0.104). There was no significant difference in peak or end lactate between groups. Selective aortic arch perfusion is effective in eliciting ROSC after HiTCA in a swine model, using either FWB or HBOC-201. Transition from SAAP to ECLS after definitive hemorrhage control is feasible, resulting in high overall survival and improvement in lactic acidosis over the study period.

Valproic acid improves survival and decreases resuscitation requirements in a swine model of prolonged damage control resuscitation.

Although damage control resuscitation (DCR) is routinely performed for short durations, prolonged DCR may be required in military conflicts as a component of prolonged field care. Valproic acid (VPA) has been shown to have beneficial properties in lethal hemorrhage/trauma models. We sought to investigate whether the addition of a single dose of VPA to a 72-hour prolonged DCR protocol would improve clinical outcomes. Fifteen Yorkshire swine (40-45 kg) were subjected to lethal (50% estimated total blood volume) hemorrhagic shock (HS) and randomized to three groups: (1) HS, (2) HS-DCR, (3) HS-DCR-VPA (150 mg/kg over 3 hours) (n = 5/cohort). In groups assigned to receive DCR, Tactical Combat Casualty Care guidelines were applied (1 hour into the shock period), targeting a systolic blood pressure of 80 mm Hg. At 72 hours, surviving animals were given transfusion of packed red blood cells, simulating evacuation to higher echelons of care. Survival rates, physiologic parameters, resuscitative fluid requirements, and laboratory profiles were used to compare the clinical outcomes. This model was 100% lethal in the untreated animals. DCR improved survival to 20%, although this was not statistically significant. The addition of VPA to DCR significantly improved survival to 80% (p < 0.01). The VPA-treated animals also had significantly (p < 0.05) higher systolic blood pressures, lower fluid resuscitation requirements, higher hemoglobin levels, and lower creatinine and potassium levels. VPA administration improves survival, decreases resuscitation requirements, and improves hemodynamic and laboratory parameters when added to prolonged DCR in a lethal hemorrhage model.

Give the trauma patient what they bleed, when and where they need it: establishing a comprehensive regional system of resuscitation based on patient need utilizing cold-stored, low-titer O+ whole blood.

Despite countless advancements in trauma care a survivability gap still exists in the prehospital setting. Military studies clearly identify hemorrhage as the leading cause of potentially survivable prehospital death. Shifting resuscitation from the hospital to the point of injury has shown great promise in decreasing mortality among the severely injured. Our regional trauma network (Southwest Texas Regional Advisory Council) developed and implemented a multiphased approach toward facilitating remote damage control resuscitation. This approach required placing low-titer O+ whole blood (LTO+ WB) at helicopter emergency medical service bases, transitioning hospital-based trauma resuscitation from component therapy to the use of whole blood, modifying select ground-based units to carry and administer whole blood at the scene of an accident, and altering the practices of our blood bank to support our new initiative. In addition, we had to provide information and training to an entire large urban emergency medical system regarding changes in policy. Through a thorough, structured program we were able to successfully implement point-of-injury resuscitation with LTO+ WB. Preliminary evaluation of our first 25 patients has shown a marked decrease in mortality compared to our historic rate using component therapy or crystalloid solutions. Additionally, we have had zero transfusion reactions or seroconversions. Transfusion at the scene within minutes of injury has the potential to save lives. As our utilization expands to our outlying network we expect to see a continued decrease in mortality among significantly injured trauma patients.

Blood is for Bleeding, Salt Water is for Cooking Pasta: An introduction to the THOR Network's Supplement for the 2018 Remote Damage Control Resuscitation Annual Symposium.

Blood is for Bleeding, Salt Water is for Cooking Pasta: An introduction to the THOR Network's Supplement for the 2018 Remote Damage Control Resuscitation Annual Symposium.

Lifeline for the front lines: blood products to support the warfighter.

Hemorrhage is the leading cause of death on the battlefield. Damage control resuscitation guidelines in the US military recommend whole blood as the preferred resuscitation product. The Armed Services Blood Program (ASBP) has initiated low-titer group O whole blood (LTOWB) production and predeployment donor screening to make whole blood more available to military forces. ASBP donor centers updated procedures and labeling for LTOWB production. Donors are screened according to US Food and Drug Administration regulations and standard operating procedures. Group O donors are tested for anti-A and anti-B titer levels. Additionally, military personnel notified for pending deployment coordinate with their local ASBP donor center to complete whole blood donor prescreening. The process consists of completing a donor history questionnaire, processing of blood samples for blood group and infectious disease testing, and titer determination for group O personnel. Since March 2016, 7940 LTOWB units have been manufactured at ASBP donor centers and shipped in support of combat operations. Additionally, ASBP donor centers have screened several thousand service members before deployment. From these screenings, the donor low titer rate was 68% and infectious disease reactive test rate was extremely low (≤0.004). Whole blood is now the preferred blood product for resuscitation of combat trauma patients. The ASBP partnered with combat forces to screen personnel before deployment. Additionally, LTOWB is manufactured and shipped in support of combat operations. These efforts are expanding the availability of LTOWB for the warfighter.