Bleeding Trauma Patients Research Articles

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BackgroundSevere trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.MethodsThe pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.ResultsThis guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.ConclusionA multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Evaluation of Resuscitative Endovascular Balloon Occlusion of the Aorta Complications in a Community-Based Trauma Center.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of management of noncompressible torso hemorrhage in trauma patients. Increased utilization has shown increased vascular complications and mortality. This study aimed to evaluate complications of REBOA placement in a community trauma setting. A 3-year retrospective review was performed of all trauma patients that underwent REBOA placement. Data collection included demographics, injury characteristics, complications, and mortality. Twenty-three patients were included, and the overall mortality was 65.2%. Most patients suffered blunt trauma (73.9%), and median ISS and TRISS (survival probability) were 24 and 42.2%, respectively. The median time to REBOA placement was 22 minutes, and hemorrhagic control was achieved in all patients. The most common complication was acute kidney injury at 34.8%. There was one complication associated with placement that required vascular intervention but did not lead to limb amputation. Resuscitative endovascular balloon occlusion of the aorta was shown to have higher rates of acute kidney injury, similar rates of vascular injury, and lower rate of limb complications compared to published literature. Resuscitative endovascular balloon occlusion of the aorta remains a useful tool for trauma resuscitation without the fear of increased complications.

Soft tissue compartment bleed—the iceberg phenomenon: a case report

Abstract Introduction Hemorrhage control is the essence of trauma care. Conventional teaching is 1 on the floor (ie, external bleeding) and 4 more (thoracic cavity, abdomen, retroperitoneum, and long bones). In this case report, we present a unique case with concealed bleeding into the soft tissue compartment leading to shock. This case triggered to consider the soft tissue compartment as the sixth potential bleeding site in trauma patients in hemorrhagic shock. Case presentation We present the case with concealed bleeding into the soft tissue compartment posing a challenge in management. On presentation, he had a pulse rate of 117 beats/min, a blood pressure of 90/60 mmHg, and a Glasgow Coma Scale (GCS) score of 9. During resuscitation, the patient's blood pressure dropped to 70/46 mmHg with a GCS of 7 of 15. He was then intubated and reevaluated. Contrast-enhanced computed tomography of the torso revealed a right scapular fracture with a large soft tissue hematoma along the right side of the neck and chest wall, extending up to the right lumbar region. Conclusion We suggest that the soft tissue compartment is the sixth potential site of internal bleeding in trauma patients, which should not be overlooked after having ruled out the other 5 sites.

Prehospital Tranexamic Acid Administration in Pediatric Trauma Patients: A Propensity-Matched Analysis of the Israeli Defense Forces Registry.

Tranexamic acid (TXA) administration confers a survival benefit in bleeding trauma patients; however, data regarding its use in pediatric patients are limited. This study evaluates the prehospital treatment with TXA in pediatric trauma patients treated by the Israel Defense Forces Medical Corps (IDF-MC). Retrospective, cohort study using the Israel Defense Forces registry, 2011-2021. Pediatric trauma patients less than 18 years old. We excluded patients pronounced dead at the scene. None. All cases of pediatric trauma in the registry were assessed for treatment with TXA. Propensity score matching was used to assess the association between prehospital TXA administration and mortality. Overall, 911 pediatric trauma patients were treated with TXA by the IDF-MC teams; the median (interquartile) age was 10 years (5-15 yr), and 72.8% were male. Seventy patients (7.6%) received TXA, with 52 of 70 (74%) receiving a 1,000 mg dose (range 200-1,000 mg). There were no prehospital adverse events associated with the use of TXA (upper limit of 95% CI for 0/70 is 4.3%). Compared with pediatric patients who did not receive TXA, patients receiving TXA were more likely to suffer from shock (40% vs 10.7%; p < 0.001), sustain more penetrating injuries (72.9% vs 31.7%; p < 0.001), be treated with plasma or crystalloids (62.9% vs 11.4%; p < 0.001), and undergo more lifesaving interventions (24.3% vs 6.2%; p < 0.001). The propensity score matching failed to identify an association between TXA and lesser odds of mortality, although a lack of effect (or even adverse effect) could not be excluded (non-TXA: 7.1% vs TXA: 4.3%, odds ratio = 0.584; 95% CI 0.084-3.143; p = 0.718). Although prehospital TXA administration in the pediatric population is feasible with adverse event rate under 5%, more research is needed to determine the appropriate approach to pediatric hemostatic resuscitation and the role of TXA in this population.

Should pre-hospital intramuscular tranexamic acid be given to trauma patients at risk of significant haemorrhage?

There are situations in the pre-hospital setting where gaining intravenous or intraosseous access is impossible or delayed. This can delay the administration of tranexamic acid to bleeding trauma patients, which may reduce its effectiveness. We sought to investigate whether some patients would benefit from early administration of tranexamic acid via the intramuscular route. Relevant observational and interventional studies were identified and summarised using a BestBET format. The current evidence supports clinicians considering intramuscular tranexamic acid in trauma patients at risk of haemorrhage when there may be significant delay in administration via intravenous or intraosseous routes.

Strategies for the Effective Management of Bleeding in Trauma Patients: A Narrative Review

Strategies for the Effective Management of Bleeding in Trauma Patients: A Narrative Review

Low-titer O Whole Blood in Management of Massive Bleeding

The management of massively bleeding patients has undergone paradigm shift. With the evolution of bundle of care in form of damage control resuscitation, early blood-based resuscitation has emerged as one of the pillars of treatment; focused at preventing shock, coagulopathy, and thrombocytopenia. Military has always relied on low-titer O whole blood (LTOWB) to provide balanced hemostatic resuscitation for bleeding patients in combat casualties. Good results from military practice have led to questioning of practices followed in civilian bleeding trauma patients. With the realization that cold-stored platelets are functionally superior for immediate hemostasis, there is renewed interest in role of LTOWB in providing early hemostatic resuscitation to massively bleeding patients. Not only does LTOWB provide all the components but it also has an advantage of simplifying resuscitation logistics by providing all the components in one bag instead of three, in situations where delay of every minute leads to increased mortality. It can provide blood-based resuscitation in scenarios where it may not otherwise be possible. It can be used across all blood groups. This review explores the concerns regarding the use of LTOWB, historical perspective, advantages, and disadvantages. Several studies have shown that LTOWB is noninferior, as compared to components, and is a safe practice, without significant transfusion-related adverse events. The use of LTOWB in bleeding patients needs further studies to explore its efficacy and safety versus component therapy.

The Saunders report into the Manchester arena attack

Journal of Paramedic PracticeVol. 14, No. 12 CommentaryThe Saunders report into the Manchester arena attackTom MallinsonTom MallinsonEmail:E-mail Address: [email protected]Lecturer, College of Remote and Offshore Medicine, MaltaSearch for more papers by this authorTom MallinsonPublished Online:6 Dec 2022https://doi.org/10.12968/jpar.2022.14.12.490AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Aldington D, Jagdish S. The fentanyl ‘lozenge’ story: from books to battlefield. J R Army Med Corps. 2014;160(2):102–104. https://doi.org/10.1136/jramc-2013-000227 Crossref, Google ScholarCarenzo L, McDonald A, Grier G. Pre-hospital oral transmucosal fentanyl citrate for trauma analgesia: preliminary experience and implications for civilian mass casualty response. Br J Anaesth. 2022;128(2):e206–e208. https://doi.org/10.1016/j.bja.2021.08.017 Crossref, Google ScholarEllerton JA, Greene M, Paal P. The use of analgesia in mountain rescue casualties with moderate or severe pain. Emerg Med J. 2013;30(6):501–505. https://doi.org/10.1136/emermed-2012-202291 Crossref, Google ScholarEvents Industry Forum. The purple guide to health, safety and welfare at music and other events. 2022. https://www.thepurpleguide.co.uk (accessed 24 November 2022) Google ScholarGrassin-Delyle S, Shakur-Still H, Picetti R et al.. Pharmacokinetics of intramuscular tranexamic acid in bleeding trauma patients: a clinical trial. Br J Anaesth. 2021;126(1):201–209. https://doi.org/10.1016/j.bja.2020.07.058 Crossref, Google ScholarJESIP. Working Together, Saving Lives. 2022. https://www.jesip.org.uk/ (accessed 28 November 2022) Google ScholarManchester Arena Inquiry. Volume 2: emergency response. 2022. https://manchesterarenainquiry.org.uk/report-volume-two (accessed 24 November 2022) Google ScholarNational Ambulance Resilience Unit. National Amnulance Resilience Unit: Preparing for the future, protecting lives today.. 2022, https://naru.org.uk/ (accessed 28 November 2022) Google ScholarOakeshott JE, Griggs JE, Wareham GM, Lyon RM; Kent Surrey Sussex Air Ambulance Trust. Feasibility of prehospital freeze-dried plasma administration in a UK helicopter emergency medical service. Eur J Emerg Med. 2019;26(5):373–378. https://doi.org/10.1097/MEJ.0000000000000585 Crossref, Google ScholarPark CL, Langlois M, Smith ER et al.. How to stop the dying, as well as the killing, in a terrorist attack. BMJ. 2020;368:m298. https://doi.org/10.1136/bmj.m298 Crossref, Google ScholarVassallo J, Moran CG, Cowburn P, Smith J. New NHS prehospital major incident triage tool: from MIMMS to MITT. Emerg Med J. 2022;39(11):800–802. https://doi.org/10.1136/emermed-2022-212569 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 December 2022Volume 14Issue 12ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 6 December 2022 Published in print 2 December 2022 Information© MA Healthcare LimitedPDF download

Development and Validation of a Dynamic Prediction Model for Massive Hemorrhage in Trauma.

Early warning prediction of massive hemorrhages can greatly reduce mortality in trauma patients. This study aimed to develop and validate dynamic prediction models for massive hemorrhage in trauma patients. Based on vital signs (e.g., heart rate, respiratory rate, pulse pressure, and peripheral oxygen saturation) time-series data and the gated recurrent unit algorithm, we characterized a group of models to flexibly and dynamically predict the occurrence of massive hemorrhages in the subsequent T hours (where T = 1, 2, and 3). Models were evaluated in terms of accuracy, sensitivity, specificity, positive predictive value, negative predictive value, F1 score, and the area under the curve (AUC). Results show that of the 2205 trauma patients selected for model development, a total of 265 (12.02%) had a massive hemorrhage. The AUCs of the model in the 1-h-group, 2-h-group, and 3-h-group were 0.763 (95% CI: 0.708-0.820), 0.775 (95% CI: 0.728-0.823), and 0.756 (95% CI: 0.715-0.797), respectively. Finally, the models were used in a web calculator and information system for the hospital emergency department. This study developed and validated a group of dynamic prediction models based on vital sign time-series data and a deep-learning algorithm to assist medical staff in the early diagnosis and dynamic prediction of a future massive hemorrhage in trauma.

Agitation in the Trauma Bay Is an Early Indicator of Hemorrhagic Shock

IntroductionAgitation on arrival in trauma patients is known as a sign of impending demise. The aim of this study is to determine outcomes for trauma patients who present in an agitated state. We hypothesized that agitation in the trauma bay is an early indicator for hemorrhage in trauma patients. MethodsWe performed a single-institution prospective observational study from September 2018 to December 2020 that included any trauma patient who arrived agitated, defined as a Richmond Agitation-Sedation Scale of +1 to +4. Variables collected included demographics, mechanism of injury, admission physiology, blood alcohol level, toxicity screen, and injury severity. The primary outcomes were need for massive transfusion (≥ 10 units) and need for emergent therapeutic intervention for hemorrhage control (laparotomy, preperitoneal pelvic packing, sternotomy, thoracotomy, or angioembolization). ResultsOf 4657 trauma admissions, 77 (2%) patients arrived agitated. Agitated patients were younger (40 versus 46, P = 0.03), predominantly male (94% versus 66%, P < 0.0001) sustained more penetrating trauma (31% versus 12%, P < 0.0001), had a lower systolic blood pressure (127 versus 137, P < 0.0001), and a higher Injury Severity Score (17 versus 9, P < 0.0001). On multivariable logistic regression, agitation was independently associated with massive transfusion (odds ratio: 2.63 [1.20-5.77], P = 0.02) and emergent therapeutic intervention for hemorrhage control (odds ratio: 2.60 [1.35-5.03], P = 0.005). ConclusionsAgitation in trauma patients may serve as an early indicator of hemorrhagic shock, as agitation is independently associated with a two-fold increase in the need for massive transfusion and emergent therapeutic intervention for hemorrhage control.

A call for disciplined patience instead of crystalloid infusion for the trauma patient

LAY SUMMARY Bleeding trauma patients require resuscitation with blood rather than an infusion of salt solution. However, a short delay often occurs from the time a resuscitation provider calls for blood and its availability. When facing a bleeding trauma patient with life-threatening low blood pressure, providers feel pressure to give immediately available salt-containing fluids. These fluids may help increase a patient’s blood pressure but will also decrease the body’s ability to deliver oxygen to organs and may increase bleeding and shock. It is proposed that providers maintain disciplined patience and wait for blood to be available rather than transfusing saltwater solutions.

Outcomes of Cold-Stored, Low Titer Group O Whole Blood Transfusions in Non-Trauma Massive Transfusion Protocol Activations in Patients with Cirrhosis

Introduction: There has been significant debate on the best transfusion practices in cirrhotic patients with massive hemorrhage. As the liver is responsible for the synthesis of many proteins involved in coagulation and anticoagulation, cirrhosis can lead to multiple coagulation abnormalities. Portal hypertension, endothelial dysfunction, renal failure, and sepsis further contribute to increased bleeding tendency in cirrhosis. A growing area of interest is transfusion of cold-stored, low-titer Group O whole blood (LTOWB). The primary advantage of LTOWB versus component-based transfusion is that it provides a balanced resuscitation of all components that is closest to physiologic blood. Additionally, it contains lower quantities of anticoagulant and preservative solution compared to individual blood components. Previous studies suggest that LTOWB is at least equivalent if not superior to component therapy in resuscitation of life-threatening hemorrhage in trauma patients. The goal of the present study is to determine whether this positive effect is also observed in cirrhotic patients requiring activation of massive transfusion protocol (MTP) for non-traumatic bleeding. Methods: We retrospectively collected data from cirrhotic patients receiving MTP with at least one unit of LTOWB transfusion between January 2019 and November 2021. LTOWB is obtained from the American Red Cross and leukoreduced with a platelet sparing filter from Terumo (Lakewood, CO). It is stored for up to 14 days, and if unused is subsequently converted to red blood cells. Low titer is defined as < 1:256. Baseline samples were collected just prior to initiation of LTOWB MTP. Post-transfusion samples were collected 24 hours following the activation of the MTP. We describe the degree of anemia, thrombocytopenia, coagulopathy, and hemolysis before and after LTOWB MTPs. The difference between post-transfusion total bilirubin and pre-transfusion total bilirubin was used as a surrogate for hemolysis. Pre- and post-transfusion thromboelastography (TEG) was used to assess clot formation, clot strength, and fibrinolysis. Data are reported as mean ± standard deviation for normally distributed variables, or median with 1st and 3rd quartiles if non-normal. The Wilcoxon signed rank test was employed to test changes between pre-and post-transfusion parameters (p<0.05 considered statistically significant). Results: Of 810 patients who received LTOWB MTP between January 2019 and November 2021, 317 were for non-traumatic bleeding, and of these 61 patients had cirrhosis. Table 1 describes patient characteristics. The most common etiology of cirrhosis was alcohol-associated liver disease. The most common cause of bleeding was upper GI bleed, followed by procedural bleeding. 16.4% of the patients received LTOWB only, and 83.6% of patients received both LTOWB and component therapy. On average, patients received one unit of red blood cells and one unit of platelets in addition to 3 units of LTOWB. Table 2 shows outcome variables. Of the 61 patients who received LTOWB MTP, Hemoglobin significantly increased 1.7 g/dL (P <0.001). Similarly, INR and PTT significantly decreased following LTOWB MTP (P <0.01 for both). Interestingly, there was a 17.5 K/cu mm decrease in platelet count (P = 0.001). The total bilirubin, calcium, and fibrinogen levels were unaffected by LTOWB MTP. The TEG K time was significantly prolonged following LTOWB MTP, while the lysis time at 30 minutes was decreased (P <0.05). One patient had a transfusion reaction. Conclusions: To our knowledge, this is the first study examining LTOWB transfusion in non-trauma patients with cirrhosis. This proof of concept study suggests that LTOWB transfusion is a feasible option for this patient population. We observed a significant improvement in hemoglobin and PTT/INR, without observed signs of hemolysis. Our TEG results suggest decreased fibrinolysis following LTOWB MTP. An important limitation of this study is the lack of an appropriate control group. Ongoing work indicates that we will soon have enough data to compare our LTOWB versus component-only MTP cohorts. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

The Clinical Application of Machine Learning-Based Models for Early Prediction of Hemorrhage in Trauma Intensive Care Units

Uncontrolled post-traumatic hemorrhage is an important cause of traumatic mortality that can be avoided. This study intends to use machine learning (ML) to build an algorithm based on data collected from an electronic health record (EHR) system to predict the risk of delayed bleeding in trauma patients in the ICU. We enrolled patients with torso trauma in the surgical ICU. Demographic features, clinical presentations, and laboratory data were collected from EHR. The algorithm was designed to predict hemoglobin dropping 6 h before it happened and evaluated the performance with 10-fold cross-validation. We collected 2218 cases from 2008 to 2018 in a trauma center. There were 1036 (46.7%) patients with positive hemorrhage events during their ICU stay. Two machine learning algorithms were used to predict ongoing hemorrhage events. The logistic model tree (LMT) and the random forest algorithm achieved an area under the curve (AUC) of 0.816 and 0.809, respectively. In this study, we presented the ML model using demographics, vital signs, and lab data, promising results in predicting delayed bleeding risk in torso trauma patients. Our study also showed the possibility of an early warning system alerting ICU staff that trauma patients need re-evaluation or further survey.

Invited Commentary: The Right Kind of Roll? Expediting Care for Bleeding Trauma Patients.

Journal of the American College of Surgeons 236(1):p 105-106, January 2023. | DOI: 10.1097/XCS.0000000000000473

A Narrative Review of Different Hemostatic Materials in Emergency Treatment of Trauma.

Hemostatic materials are very important for the treatment of a large number of bleeding trauma patients in battlefield and disaster environments. Different types of hemostatic materials need to be used for emergency hemostasis according to different injury parts and severity. At present, the first-aid hemostatic materials have been well applied to the bleeding of body surface wounds, limbs, and junctions, but there are still no ideal hemostatic materials in the early treatment of first aid for the deep and incompressible bleeding of thoracoabdominal cavity and visceral organs. This paper reviews the classification and mechanism of hemostatic materials, as well as the application and research progress in trauma emergency, so as to provide reference for the application of hemostatic materials in early first-aid emergency.

Effect of Race on the Association Between Whole Blood Transfusion and Mortality in Bleeding Trauma Patients

INTRODUCTION: Preliminary studies have demonstrated a mortality benefit of whole blood (WB) vs blood component therapy in trauma resuscitation, but WB remains a scarce product in trauma centers and necessitates appropriate resource allocation. The purpose of this study was to evaluate for disparities in WB use based on race and to determine whether this affected mortality. METHODS: A prospective MCT involving 14 trauma centers was performed. All trauma patients who received blood transfusions as part of their initial resuscitation were included. A multivariable logistic regression model was used to measure the association between WB and mortality, controlling for Injury Severity Score, shock index, mechanism of injury, transfusion volume, and center. The effect of race (non-Black vs Black) on WB use and mortality was explored. RESULTS: Of 1,621 patients (age 40 years, 83% male, 42% Black), 1,178 (73%) patients received at least 1 unit of WB. When controlling for Injury Severity Score, shock index, mechanism of injury, transfusion volume, and center, Black patients were significantly less likely to receive WB than were non-Black patients (Table). Race modified the association between blood transfusion type and mortality. In multivariable logistic regression, we found that among patients who did not get WB, Black patients were more likely to die compared with non-Black patients (odds ratio 2.12, 95% CI 1.42 to 3.21).TableCONCLUSION: Black trauma patients were less likely to receive WB vs blood component therapy during initial resuscitation for hemorrhage. Race modified the risk of mortality, making Black patients who did not receive WB more likely to die vs non-Black patients.

Early identification of bleeding in trauma patients: external validation of traumatic bleeding scores in the Swiss Trauma Registry

BackgroundEarly identification of bleeding at the scene of an injury is important for triage and timely treatment of injured patients and transport to an appropriate facility. The aim of the study is to compare the performance of different bleeding scores.MethodsWe examined data from the Swiss Trauma Registry for the years 2015–2019. The Swiss Trauma Registry includes patients with major trauma (injury severity score (ISS) ≥ 16 and/or abbreviated injury scale (AIS) head ≥ 3) admitted to any level-one trauma centre in Switzerland. We evaluated ABC, TASH and Shock index (SI) scores, used to predict massive transfusion (MT) and the BATT score and used to predict death from bleeding. We evaluated the scores when used prehospital and in-hospital in terms of discrimination (C-Statistic) and calibration (calibration slope). The outcomes were early death within 24 h and the receipt of massive transfusion (≥ 10 Red Blood cells (RBC) units in the first 24 h or ≥ 3 RBC units in the first hour).ResultsWe examined data from 13,222 major trauma patients. There were 1,533 (12%) deaths from any cause, 530 (4%) early deaths within 24 h, and 523 (4%) patients who received a MT (≥ 3 RBC within the first hour). In the prehospital setting, the BATT score had the highest discrimination for early death (C-statistic: 0.86, 95% CI 0.84–0.87) compared to the ABC score (0.63, 95% CI 0.60–0.65) and SI (0.53, 95% CI 0.50–0.56), P < 0.001. At hospital admission, the TASH score had the highest discrimination for MT (0.80, 95% CI 0.78–0.82). The positive likelihood ratio for early death were superior to 5 for BATT, ABC and TASH. The negative likelihood ratio for early death was below 0.1 only for the BATT score.ConclusionsThe BATT score accurately estimates the risk of early death with excellent performance, low undertriage, and can be used for prehospital treatment decision-making. Scores predicting MT presented a high undertriage rate. The outcome MT seems not appropriate to stratify the risk of life-threatening bleeding.Trial registration: Clinicaltrials.gov, NCT04561050. Registered 15 September 2020.

The haemostatic effect of deep-frozen platelets versus room temperature-stored platelets in the treatment of surgical bleeding: MAFOD—study protocol for a randomized controlled non-inferiority trial

BackgroundThe Netherlands Armed Forces have been successfully using deep-frozen (− 80 °C) thrombocyte concentrate (DTC) for the treatment of (massive) bleeding trauma patients in austere environments since 2001. However, high-quality evidence for the effectiveness and safety of DTCs is currently lacking. Therefore, the MAssive transfusion of Frozen bloOD (MAFOD) trial is designed to compare the haemostatic effect of DTCs versus room temperature-stored platelets (RSP) in the treatment of surgical bleeding.MethodsThe MAFOD trial is a single-blinded, randomized controlled non-inferiority trial and will be conducted in three level 1 trauma centres in The Netherlands. Patients 12 years or older, alive at hospital presentation, requiring a massive transfusion including platelets and with signed (deferred) consent will be included. The primary outcome is the percentage of patients that have achieved haemostasis within 6 h and show signs of life. Haemostasis is defined as the time in minutes from arrival to the time of the last blood component transfusion (plasma/platelets or red blood cells), followed by a 2-h transfusion-free period. This is the first randomized controlled study investigating DTCs in trauma and vascular surgical bleeding.DiscussionThe hypothesis is that the percentage of patients that will achieve haemostasis in the DTC group is at least equal to the RSP group (85%). With a power of 80%, a significance level of 5% and a non-inferiority limit of 15%, a total of 71 patients in each arm are required, thus resulting in a total of 158 patients, including a 10% refusal rate. The data collected during the study could help improve the use of platelets during resuscitation management. If proven non-inferior in civilian settings, frozen platelets may be used in the future to optimize logistics and improve platelet availability in rural or remote areas for the treatment of (massive) bleeding trauma patients in civilian settings.Trial registrationClinicalTrials.gov NCT05502809. Registered on 16 August 2022.

Why are bleeding trauma patients still dying? Towards a systems hypothesis of trauma.

Over the years, many explanations have been put forward to explain early and late deaths following hemorrhagic trauma. Most include single-event, sequential contributions from sympathetic hyperactivity, endotheliopathy, trauma-induced coagulopathy (TIC), hyperinflammation, immune dysfunction, ATP deficit and multiple organ failure (MOF). We view early and late deaths as a systems failure, not as a series of manifestations that occur over time. The traditional approach appears to be a by-product of last century’s highly reductionist, single-nodal thinking, which also extends to patient management, drug treatment and drug design. Current practices appear to focus more on alleviating symptoms rather than addressing the underlying problem. In this review, we discuss the importance of the system, and focus on the brain’s “privilege” status to control secondary injury processes. Loss of status from blood brain barrier damage may be responsible for poor outcomes. We present a unified Systems Hypothesis Of Trauma (SHOT) which involves: 1) CNS-cardiovascular coupling, 2) Endothelial-glycocalyx health, and 3) Mitochondrial integrity. If central control of cardiovascular coupling is maintained, we hypothesize that the endothelium will be protected, mitochondrial energetics will be maintained, and immune dysregulation, inflammation, TIC and MOF will be minimized. Another overlooked contributor to early and late deaths following hemorrhagic trauma is from the trauma of emergent surgery itself. This adds further stress to central control of secondary injury processes. New point-of-care drug therapies are required to switch the body’s genomic and proteomic programs from an injury phenotype to a survival phenotype. Currently, no drug therapy exists that targets the whole system following major trauma.

Impact of the implementation of a trauma system on compliance with evidence-based clinical management guidelines in penetrating thoracic trauma.

Since 2014, a trauma system (TS) for the Provence-Alpes-Cote-d'Azur (PACA) region has been set up with protocols based on the European guidelines for the management of bleeding trauma patients. The present study aims to assess compliance with protocols in penetrating thoracic trauma on admission to a level I trauma centre and to determine whether compliance impacts morbidity and mortality. This multicentric pre-post study included all penetrating thoracic trauma patients referred to Marseille area level I centres between January 2009 and December 2019. On the basis of the European guidelines, eight objectively measurable recommendations concerning the in-hospital trauma care for the first 24h were analysed. Per-patient and per-criterion compliance rates and their impact on morbidity and mortality were evaluated before and after TS implementation. A total of 426 patients were included. No differences between the two groups (before and after 2014) were reported for demographics or injury severity. The median (interquartile range) per-patient compliance rate increased from 67% [0.50; 0.75] to 75% [0.67; 1.0] (p < 0.01) after implementation of a TS. The 30-day morbidity-mortality was, respectively, of 17% (30/173) and 13% (32/253) (p = 0.18) before and after TS implementation. A low per-patient compliance rate was associated with an increase in the 30-day morbidity-mortality rate (p < 0.01). Severity score-adjusted per-patient compliance rates were associated with decreased 30-day morbidity-mortality (odds ratio [IC 95%] = 0.98 [0.97; 0.99] p = 0.01). Implementation of a TS was associated with better compliance to European recommendations and better outcomes for severe trauma patients. These findings should encourage strict adherence to European trauma protocols to ensure the best patient outcomes.