OBJECTIVES:Experience in the ongoing wars in Iraq and Afghanistan confirm that faster transport combined with effective prehospital interventions improves the outcomes of patients suffering ...hemorrhagic shock. Outcomes of patients with hemorrhagic shock and extremity bleeding have improved with widespread use of tourniquets and early balanced transfusion therapy. Conversely, civilian patients suffering truncal bleeding and shock have the same mortality (46%) over the last 20 years. To understand how to decrease this substantial mortality, one must first critically evaluate all phases of care from point of injury to definitive hemorrhage control in the operating room.
DATA SOURCES:Limited literature review.
DATA SYNTHESIS:The peak time to death after severe truncal injury is within 30 minutes of injury. However, when adding prehospital transport time, time spent in the emergency department, followed by the time in the operating room, it currently takes 2.1 hours to achieve definitive truncal hemorrhage control. This disparity in uncontrolled truncal bleeding and time to hemorrhage control needs to be reconciled. Prehospital and emergency department whole blood transfusion and temporary truncal hemorrhage control are now possible.
CONCLUSIONS:The importance of rapid transport, early truncal hemorrhage control and whole blood transfusion is now widely recognized. Prehospital temporary truncal hemorrhage control and whole blood transfusion should offer the best possibility of improving patient outcomes after severe truncal injury.
Abstract Background Fibrinolysis is a physiologic process to maintain microvascular patency by breaking down excessive fibrin clot. Hyperfibrinolysis (HF) is associated with a doubling of mortality. ...Fibrinolysis shutdown (SD), an acute impairment of fibrinolysis, has been recognized as a risk factor for increased mortality. The purpose of this study was to assess the incidence and outcomes of fibrinolysis phenotypes in two urban trauma centers. Study Design Injured patients admitted 2010-2013, who were ≥18 years of age, had an injury severity score (ISS) >15 were included in the analysis. Admission fibrinolysis phenotypes were determined by the clot lysis at 30 minutes (LY30): SD ≤0.8%, physiologic 0.9-2.9%, HF ≥3%. Logistic regression was used to adjust for age, arrival blood pressure, ISS, mechanism, and facility. Results 2540 patients met inclusion. Median age was 39(IQR 26-55) and median ISS was 25(IQR 20-33) with a mortality rate of 21%. Fibrinolysis shutdown was the most common phenotype (46%) followed by physiologic (36%) and hyperfibrinolysis(18%). HF was associated with the highest death rate (34%), followed by SD(22%), and physiologic (14%, p<0.001). The risk of mortality remained increased for HF(OR=3.3, 95%C: 2.4-4.6, p<0.0001) and SD(OR 1.6 95%CI 1.3-2.1, p=0.0003) compared to physiologic when adjusting for age, ISS, mechanism, head injury, and blood pressure (AUROC=0.82, 95% CI 0.80-0.84). Conclusions Fibrinolysis SD is the most common phenotype upon admission and is associated with increased mortality. Moreover, these data provide additional evidence of distinct phenotypes of coagulation impairment and that individualized hemostatic therapy may be required.
The majority of potentially preventable deaths after trauma are related to hemorrhage and occur early after injury, with the largest number of deaths occurring before hospital arrival. Approximately ...one‐fourth of trauma deaths may be potentially preventable through early medical and surgical interventions. Interventions dedicated to bleeding control and hemostatic resuscitation have demonstrated merit in decreasing hemorrhagic injury mortality. Advancing these novel strategies to the casualty in the prehospital phase of care, particularly in tactical or austere environments, may prove beneficial for hemorrhage mitigation to temporize the window of survival to definitive care. Future studies of resuscitation and survival after traumatic injury must include analysis of prehospital deaths to fully understand the outcomes of early interventions.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Ten percent of deaths worldwide are due to trauma, and it is the third most common cause of death in the United States. Despite a profound upregulation in procoagulant mechanisms, one-quarter of ...trauma patients present with laboratory-based evidence of trauma-induced coagulopathy (TIC), which is associated with poorer outcomes including increased mortality. The most common causes of death after trauma are hemorrhage and traumatic brain injury (TBI). The management of TIC has significant implications in both because many hemorrhagic deaths could be preventable, and TIC is associated with progression of intracranial injury after TBI. This review covers the most recent evidence and advances in our understanding of TIC, including the role of platelet dysfunction, endothelial activation, and fibrinolysis. Trauma induces a plethora of biochemical and physiologic changes, and despite numerous studies reporting differences in coagulation parameters between trauma patients and uninjured controls, it is unclear whether some of these differences may be “normal” after trauma. Comparisons between trauma patients with differing outcomes and use of animal studies have shed some light on this issue, but much of the data continue to be correlative with causative links lacking. In particular, there are little data linking the laboratory-based abnormalities with true clinically evident coagulopathic bleeding. For these reasons, TIC continues to be a significant diagnostic and therapeutic challenge.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include ...minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.
John B Holcomb summarizes recent conceptual and practical advances in trauma care, in both military and civilian settings, and presents directions for future research.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Hemorrhage remains the leading cause of death in trauma patients. Proximal aortic occlusion, usually performed by direct aortic cross-clamping via thoracotomy, can provide temporary hemodynamic ...stability, permitting definitive injury repair. Resuscitative endovascular balloon occlusion of the aorta (REBOA) uses a minimally invasive, transfemoral balloon catheter, which is rapidly inserted retrograde and inflated for aortic occlusion, and may control inflow and allow time for hemostasis. We compared resuscitative thoracotomy with aortic cross-clamping (RT) with REBOA in trauma patients in profound hemorrhagic shock.
Trauma registry data was used to compare all patients undergoing RT or REBOA during an 18-month period from two Level 1 trauma centers.
There was no difference between RT (n = 72) and REBOA groups (n = 24) in terms of demographics, mechanism of injury, or Injury Severity Scores (ISSs). There was no difference in chest and abdominal Abbreviated Injury Scale (AIS) scores between the groups. However, the RT patients had lower extremity AIS score as compared with REBOA patients (1.5 0-3 vs. 4 3-4, p < 0.001). Of the 72 RT patients, 45 (62.5%) died in the emergency department, 6 (8.3%) died in the operating room, and 14 (19.4%) died in the intensive care unit. Of the 24 REBOA patients, 4 (16.6%) died in the emergency department, 3 (12.5%) died in the operating room, and 8 (33.3%) died in the intensive care unit. In comparing location of death between the RT and REBOA groups, there were a significantly higher number of deaths in the emergency department among the RT patients as compared with the REBOA patients (62.5% vs. 16.7%, p < 0.001). REBOA had fewer early deaths and improved overall survival as compared with RT (37.5% vs. 9.7%, p = 0.003).
REBOA is feasible and controls noncompressible truncal hemorrhage in trauma patients in profound shock. Patients undergoing REBOA have improved overall survival and fewer early deaths as compared with patients undergoing RT.
Therapeutic study, level IV.
The early use of fresh frozen plasma as a resuscitative agent after hemorrhagic shock has been associated with improved survival, but the mechanism of protection is unknown. Hemorrhagic shock causes ...endothelial cell dysfunction and we hypothesized that fresh frozen plasma would restore endothelial integrity and reduce syndecan-1 shedding after hemorrhagic shock. A prospective, observational study in severely injured patients in hemorrhagic shock demonstrated significantly elevated levels of syndecan-1 (554±93 ng/ml) after injury, which decreased with resuscitation (187±36 ng/ml) but was elevated compared to normal donors (27±1 ng/ml). Three pro-inflammatory cytokines, interferon-γ, fractalkine, and interleukin-1β, negatively correlated while one anti-inflammatory cytokine, IL-10, positively correlated with shed syndecan-1. These cytokines all play an important role in maintaining endothelial integrity. An in vitro model of endothelial injury then specifically examined endothelial permeability after treatment with fresh frozen plasma orlactated Ringers. Shock or endothelial injury disrupted junctional integrity and increased permeability, which was improved with fresh frozen plasma, but not lactated Ringers. Changes in endothelial cell permeability correlated with syndecan-1 shedding. These data suggest that plasma based resuscitation preserved endothelial syndecan-1 and maintained endothelial integrity, and may help to explain the protective effects of fresh frozen plasma after hemorrhagic shock.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IMPORTANCE: The term golden hour was coined to encourage urgency of trauma care. In 2009, Secretary of Defense Robert M. Gates mandated prehospital helicopter transport of critically injured combat ...casualties in 60 minutes or less. OBJECTIVES: To compare morbidity and mortality outcomes for casualties before vs after the mandate and for those who underwent prehospital helicopter transport in 60 minutes or less vs more than 60 minutes. DESIGN, SETTING, AND PARTICIPANTS: A retrospective descriptive analysis of battlefield data examined 21 089 US military casualties that occurred during the Afghanistan conflict from September 11, 2001, to March 31, 2014. Analysis was conducted from September 1, 2014, to January 21, 2015. MAIN OUTCOMES AND MEASURES: Data for all casualties were analyzed according to whether they occurred before or after the mandate. Detailed data for those who underwent prehospital helicopter transport were analyzed according to whether they occurred before or after the mandate and whether they occurred in 60 minutes or less vs more than 60 minutes. Casualties with minor wounds were excluded. Mortality and morbidity outcomes and treatment capability–related variables were compared. RESULTS: For the total casualty population, the percentage killed in action (16.0% 386 of 2411 vs 9.9% 964 of 9755; P < .001) and the case fatality rate (CFR 13.7 469 of 3429 vs 7.6 1344 of 17 660; P < .001) were higher before vs after the mandate, while the percentage died of wounds (4.1% 83 of 2025 vs 4.3% 380 of 8791; P = .71) remained unchanged. Decline in CFR after the mandate was associated with an increasing percentage of casualties transported in 60 minutes or less (regression coefficient, –0.141; P < .001), with projected vs actual CFR equating to 359 lives saved. Among 4542 casualties (mean injury severity score, 17.3; mortality, 10.1% 457 of 4542) with detailed data, there was a decrease in median transport time after the mandate (90 min vs 43 min; P < .001) and an increase in missions achieving prehospital helicopter transport in 60 minutes or less (24.8% 181 of 731 vs 75.2% 2867 of 3811; P < .001). When adjusted for injury severity score and time period, the percentage killed in action was lower for those critically injured who received a blood transfusion (6.8% 40 of 589 vs 51.0% 249 of 488; P < .001) and were transported in 60 minutes or less (25.7% 205 of 799 vs 30.2% 84 of 278; P < .01), while the percentage died of wounds was lower among those critically injured initially treated by combat support hospitals (9.1% 48 of 530 vs 15.7% 86 of 547; P < .01). Acute morbidity was higher among those critically injured who were transported in 60 minutes or less (36.9% 295 of 799 vs 27.3% 76 of 278; P < .01), those severely and critically injured initially treated at combat support hospitals (severely injured, 51.1% 161 of 315 vs 33.1% 104 of 314; P < .001; and critically injured, 39.8% 211 of 530 vs 29.3% 160 of 547; P < .001), and casualties who received a blood transfusion (50.2% 618 of 1231 vs 3.7% 121 of 3311; P < .001), emphasizing the need for timely advanced treatment. CONCLUSIONS AND RELEVANCE: A mandate made in 2009 by Secretary of Defense Gates reduced the time between combat injury and receiving definitive care. Prehospital transport time and treatment capability are important factors for casualty survival on the battlefield.
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