Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.
The multidisciplinary Task Force for ...Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.
Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.
This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.
Traumatic brain injury represents the leading cause of death in young individuals. Various animal models have been developed to mimic human closed head injury (CHI). Widely used models induce head ...injury by lateral fluid percussion, a controlled cortical impact or impact acceleration. The presented model induces a CHI by a standardized weight-drop device inducing a focal blunt injury over an intact skull without pre-injury manipulations. The resulting impact triggers a profound neuroinflammatory response within the intrathecal compartment with high consistency and reproducibility, leading to neurological impairment and breakdown of the blood-brain barrier. In this protocol, we define standardized procedures for inducing CHI in mice and determine various severity grades of CHI through modulation of the weight falling height. In experienced hands, this CHI model can be carried out in as little as 30 s per animal, with additional time required for subsequent posttraumatic analysis and data collection.
Traumatic pelvic ring injuries continue to represent a major challenge due to the high rates of post-injury mortality of around 30-40% in the peer-reviewed literature. The main root cause of ...potentially preventable mortality relates to the delayed recognition of the extent of retroperitoneal hemorrhage and post-injury coagulopathy. The understanding of the underlying pathophysiology of pelvic trauma is predicated by classification systems for grading of injury mechanism and risk stratification for developing post-injury coagulopathy with subsequent uncontrolled exsanguinating hemorrhage. This review article elaborates on the current understanding of the pathophysiology of severe pelvic trauma with a focus on the underlying mechanisms of retroperitoneal bleeding and associated adverse outcomes.
Abstract The use of local antibiotics for the prevention of infection in the setting of open fractures and as part of the treatment of osteomyelitis is well established. Antibiotics are most commonly ...incorporated into polymethylmethacrylate (PMMA) cement, which can then be formed into beads, moulded to fit a bone defect or used to coat a guide wire or IM nail. Newer delivery vehicles and techniques are being evaluated to improve upon these methods. Many factors influence how local antibiotics are applied. Treatment strategies are challenging to standardise due to the variability of clinical presentations. The presence of hardware, upper versus lower extremity, healed versus non-healed fracture and quality of soft tissues overlying the affected bone, as well as patients’ comorbidities all need to be considered. Despite the accepted use of local antibiotic therapy in orthopaedic trauma, high-quality evidence regarding the use of local antibiotics is lacking. Indications, techniques, dosages, types of antibiotics, elution properties and pharmacokinetics are poorly defined in the clinical setting. The purpose of our manuscript is to review current strategies and provide practical tips for local application of antibiotics in orthopaedic trauma. We focus on delivery vehicles, types of antibiotics, dosage recommendations when mixed with PMMA and indications.
The lack of formal training programs for peer reviewers places the scientific quality of biomedical publications at risk, as the introduction of 'hidden' bias may not be easily recognized by the ...reader. The exponential increase in the number of manuscripts submitted for publication worldwide, estimated in the millions annually, overburdens the capability of available qualified referees. Indeed, the workload imposed on individual reviewers appears to be reaching a 'breaking point' that may no longer be sustainable. Some journals have made efforts to improve peer review via structured guidelines, courses for referees, and employing biostatisticians to ensure appropriate study design and analyses. Further strategies designed to incentivize and reward peer review work include journals providing continuing medical education (CME) credits to individual referees by defined criteria for timely and high-quality evaluations. Alternative options to supplement the current peer review process consist of 'post-publication peer review,' 'decoupled peer review,' 'collaborative peer review,' and 'portable peer review'. This article outlines the shortcomings and flaws in the current peer review system and discusses new innovative options on the horizon.
A 2015 American Association for the Surgery of Trauma trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group ...revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized that preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality.
In 2004, we initiated a PPP protocol for pelvic fracture hemorrhage.
During the 11-year study, 2,293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age, 44 ± 2 years; Injury Severity Score (ISS), 48 ± 1.2). The lowest emergency department systolic blood pressure was 74 mm Hg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions before SICU admission compared with the 24 postoperative hours were 8 versus 3 units (p < 0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush.Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the operating room at 89 and 100 minutes after arrival, whereas 1 died 9 hours after arrival.
PPP results in a shorter time to intervention and lower mortality compared with modern series using AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be used for pelvic fracture-related bleeding in the patient who remains unstable despite initial transfusion.
Therapeutic study, level IV.
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