Background
Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact ...of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion.
Study design and methods
A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6‐h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed.
Results
A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (−0.28 vs. −0.002, p < .001). In a propensity‐matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05).
Discussion
This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi‐institutional prospective studies are needed.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
The mortality from hemorrhage in trauma patients remains high. Early balanced resuscitation improves survival. These truths, balanced with the availability of local resources and our goals for ...positive regional impact, were the foundation for the development of our prehospital whole blood initiative-using low-titer cold-stored O RhD-positive whole blood. The main concern with use of RhD-positive blood is the potential development of isoimmunization in RhD-negative patients. We used our retrospective massive transfusion protocol (MTP) data to analyze the anticipated risk of this change in practice. In 30 months, of 124 total MTP patients, only one female of childbearing age that received an MTP was RhD-negative. With the risk of isoimmunization very low and the benefit of increased resources for the early administration of balanced resuscitation high, we determined that the utilization of low-titer cold-stored O RhD-positive whole blood would be safe and best serve our community.
Although uncommon, Morel-Lavallée lesions (also called closed degloving injuries) are associated with considerable morbidity in trauma patients. There is lack of consensus regarding proper management ...of these lesions. Management options include nonoperative therapies, along with percutaneous and operative techniques. We sought to define the factors associated with failure of percutaneous aspiration to better identify patients requiring immediate operative management.
We retrospectively searched our prospectively collected database for patient records containing the terms Morel-Lavallée, closed degloving injury, or posttraumatic seroma from February 2, 2004, through December 23, 2011. Treatment methods included compression wraps or observation (nonoperative management), percutaneous aspiration, or operative management with incision/drainage or formal debridement of skin and soft tissues that resulted in wound vacuum-assisted closure placement and/or split-thickness skin graft (operative management). The treatment groups were compared using univariate analysis and χ testing.
We identified 79 patients with 87 Morel-Lavallée lesions in the setting of trauma. Most were caused by motor vehicle collisions (25%). No difference was observed between the treatment groups in sex, body mass index, anticoagulation treatment, diabetes mellitus, smoking history, or alcohol use. The percutaneous aspiration group had higher rates of recurrence (56% vs. 19% and 15% in nonoperative and operative groups, respectively). The percentage of patients who had aspiration of more than 50 mL of fluid was higher for lesions that recurred than for lesions that resolved (83% vs. 33%, p = 0.02).
Aspiration of more than 50 mL of fluid from Morel-Lavallée lesions was much more common among lesions that recurred (83%) than among those that resolved (33%). We therefore recommend that aspiration of more than 50 mL of fluid from a Morel-Lavallée lesion prompts operative intervention. We have now adopted this as a practice management guideline.
Therapeutic/care management study, level III.
BACKGROUND
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.
MATERIALS AND METHODS
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.
RESULTS
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.
CONCLUSION
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.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Thoracic endovascular aortic repair (TEVAR) is the preferred operative treatment of blunt thoracic aortic injuries (BTAIs). Its use is associated with improved outcomes compared with open surgical ...repair and nonoperative management. However, the optimal time from injury to repair is unknown and remains a subject of debate across different societal practice guidelines. The purpose of this study was to evaluate national trends in the management of BTAI, with a specific focus on the impact of timing of repair on outcomes.
Using the National Trauma Data Bank, we identified adult patients with BTAI between 2012 and 2017. Patients with prehospital or emergency department cardiac arrest or incomplete data sets were excluded from analysis. Patients were classified according to timing of repair: group 1, <24 hours; and group 2, ≥24 hours. The primary outcome evaluated was in-hospital mortality; secondary outcomes included overall hospital and intensive care unit length of stay. Multivariable logistic regression was performed to identify independent predictors of mortality.
The analysis was completed for 2821 patients who underwent TEVAR for BTAI with known operative times. The overall mortality in the patient cohort was 8.4% (238/2821); 75% of patients undergoing TEVAR were repaired within 24 hours. Mortality was more than twofold greater in group 1 compared with group 2 (9.8% 207/2118 vs 4.4% 31/703; P = .001). This mortality benefit persisted across injury severity groups and was independent of the presence of serious extrathoracic injuries. Logistic regression analysis, adjusting for age ≥65 years, Glasgow Coma Scale score ≤8, systolic blood pressure ≤90 mm Hg at admission, and serious extrathoracic injuries, showed a higher adjusted mortality in group 1 (odds ratio, 2.54; 95% confidence interval, 1.66-3.91; P = .001).
The majority of patients with BTAI undergo endovascular repair within 24 hours of injury. Patients undergoing delayed repair have improved survival compared with those repaired within the first 24 hours of injury in spite of similar injury patterns and severity. In patients with BTAIs without signs of imminent rupture, delaying endovascular repair beyond 24 hours after injury should be considered.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
This paper reports that various thermodynamic properties in aqueous media for certain individual ions and for compounds are linear functions of the inverse cube root of the solid respective ionic and ...compound solid state volumes, V m −1/3 . This is similar to the situation which has been fully exploited in solid state thermodynamics and out of which volume-based thermodynamics, VBT, evolved. A short resume of these various VBT applications is provided for the general reader and an improved lattice potential energy equation emerges using the state of the art data presented in this paper.
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IJS, KILJ, NUK, UL, UM, UPUK
This review describes the necessity, evolution, and current state of prehospital blood programs in the United States. Less than 1% of 9-1-1 Ground Emergency Medical Service agencies have been able to ...successfully implement prehospital blood transfusions as part of a resuscitation strategy for patients in hemorrhagic shock despite estimates that annually between 54,000 and 900,000 patients may benefit from its use. The use of prehospital blood transfusions as a tool for managing hemorrhagic shock has barriers to overcome to ensure it becomes widely available to patients throughout the United States. Barriers include 1) current state Emergency Medical Services clinicians' scope of practice limitations, 2) program costs and reimbursement of blood products, 3) no centralized data collection process for prehospital hemorrhagic shock and patient outcomes, 4) collaboration between prehospital agencies, blood suppliers, and hospital clinicians and transfusion service activities. The following paper identifies barriers and a proposed roadmap to reduce death due to prehospital hemorrhage.
The optimal candidates for resuscitative endovascular balloon occlusion of the aorta (REBOA) remain unclear. We hypothesized that patients who experience delays in surgical intervention would benefit ...from REBOA.
Using the Japan Trauma Databank (2014–2019), patients transferred to the operating room (OR) within 3 h were identified. Patients treated with REBOA were matched with those without REBOA using propensity scores, and further divided based on the transfer time to OR: ≤ 1 h (early), 1–2 h (delayed), and >2 h (significantly-delayed). Survival to discharge was compared.
Among 5258 patients, 310 underwent REBOA. In 223 matched pairs, patients treated with REBOA had improved survival (56.5% vs. 31.8%; p < 0.01), although in-hospital mortality was reduced by REBOA only in the delayed and significantly-delayed subgroups (HR = 0.43 0.28–0.65 and 0.42 0.25–0.71).
REBOA-treated trauma patients who experience delays in surgical intervention (>1 h) have improved survival.
•In trauma patients, REBOA use was associated with improved survival to discharge.•Patients who experienced delays in surgical intervention benefited from REBOA.•Survival benefit with REBOA was not found in patients transferred to OR within 1 h.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Hemorrhage is the most common cause of preventable death in trauma patients. These mortalities might be prevented with prehospital transfusion. We sought to characterize injured patients requiring ...massive transfusion to determine the potential impact of a prehospital whole blood transfusion program.The primary goal of this analysis was to determine a method to identify patients at risk for massive transfusion in the prehospital environment. Many of the existing predictive models require laboratory values and/or sonographic evaluation of the patient after arrival at the hospital. Development of an algorithm to predict massive transfusion protocol (MTP) activation could lead to an easy-to-use tool for prehospital personnel to determine when a patient needs blood transfusion.
Using our Level I trauma center's registry, we retrospectively identified all adult trauma patients from January 2015 to August 2017 requiring activation of the massive transfusion protocol (MTP). Patients who were <18 years old, >89 years old, prisoners, pregnant women, and/or with non-traumatic hemorrhage were excluded from the study. We retrospectively collected data including: demographics, blood utilization, variable outcome data (survival, length of stay, ICU days, ventilator days), prehospital vital signs, prehospital transport times, and injury severity scores. The independent samples t-test and chi square test was used to compare the group that died to the group that survived. P values less than 0.05 were considered significant. Based upon age and mechanism of injury, relative risk of death was calculated. Graphs were generated using Microsoft Excel software to plot patient variables.
Our study population of 102 MTP patients had an average age of 42 years, average injury severity score (ISS) of 29, consisted of 80% males (82/102), and was 66% blunt trauma (67/102). The all-cause mortality was 67% (68/102). The positive predictive value of death for patients with pulse pressure (PP)<45 and shock index (SI)>1 was 0.78 for all patients, but was 0.79 and 0.92 for blunt injury and elderly patients, respectively.
Our data demonstrate a high mortality rate in trauma patients who require MTP despite short transport times, indicating the need for early intervention in the prehospitalss environment. Given our understanding that the most severely injured patients in hemorrhagic shock require blood resuscitation, this study demonstrates that this subset of trauma patients requiring massive transfusion can be identified in the prehospital setting. We recommend using EMS pulse pressure in combination with shock index to serve as a trigger for initiation of prehospital whole blood transfusion.
Therapeutic/Care Management, Level V.
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