Management of bleeding following major trauma: an updated European guideline

High plasma to red blood cell ratios are associated with lower mortality rates in patients receiving multiple transfusion (4≤red blood cell units<10) during acute trauma resuscitation

BACKGROUND

Benefits of high ratios of fresh frozen plasma (FFP) to packed red blood cells (pRBC) in massively transfused trauma patients have been reported previously. This study aimed to assess the effect of higher FFP:pRBC ratios on outcome in patients receiving less than massive transfusion during acute trauma care.

METHODS

The multicenter trauma registry of the German Trauma Society (2005-2008) was retrospectively analyzed for patients aged≥16 years with an Injury Severity Score≥16 who had received multiple but not massive transfusion between emergency room arrival and intensive care unit (ICU) admission, i.e., at least 4 but less than 10 pRBC units (4≤pRBC units<10). Patients who died within 1 hour after hospital admission were excluded. Three groups were analyzed according to FFP:pRBC ratio: low (<1:1, LR), balanced (1:1, BR), and high ratio (>1:1, HR). BR was defined as pRBC units=FFP units±1 FFP unit.

RESULTS

A total of 1,362 patients met study criteria (LR=760, BR=392, and HR=210). Patient characteristics were similar among groups. For the three groups (LR, BR, and HR) sepsis was reported in 17.1%, 18.2%, and 17.6% (p=0.9), incidence of multiple organ failure was 49.1%, 47.9%, and 52.4% (p=0.6), whereas mortality was 26.8%, 21.7%, and 15.2% (p=0.001), respectively. Ongoing pRBC-transfusion after ICU admission occurred in 68.1%, 66.7%, and 53.9% (p<0.001), respectively. ICU/hospital lengths of stay were comparable between groups. Multivariate logistic regression identified a high FFP:pRBC ratio as independent predictor for survival (odds ratio, 0.52, p=0.013).

CONCLUSIONS

Trauma patients receiving less than massive transfusion might also benefit from higher FFP:pRBC ratios, as these were associated with significantly lower mortality rates and decreased blood product utilization during subsequent ICU treatment, whereas morbidity was comparable among groups. Additional prospective trials are necessary.

Goal-directed Coagulation Management in Major Trauma

Severe tissue trauma is frequently associated with hemorrhagic shock and subsequent pronounced coagulopathy [1]. Uncontrolled bleeding is the second most common cause of death, and hemorrhage is directly responsible for 40 % of all trauma-related deaths [2]. Coagulopathy can be detected with standard coagulation tests immediately after arrival in the emergency room (ER) in approximately 25–35 % of all trauma patients [1], [2]. Moreover, early trauma-induced coagulopathy is associated with a 4-fold increase in mortality [1]. Blood coagulation monitoring is essential in order to assess the underlying coagulation disorder and to tailor hemostatic treatment. Thromboelastometry (TEM) and thrombelastography (TEG) are promising point-of-care technologies providing rapid information on the initiation process of clot formation, clot quality, and stability of the clot [3].

[Treatment of polytrauma in the intensive care unit]

The treatment of severely injured trauma patients (polytrauma) is one of the outstanding challenges in medical care. Early in the initial course the patient's diagnostics have to be scrupulously reevaluated by an interdisciplinary team (tertiary trauma survey) to reduce deleterious sequelae of missed injuries after the initial assessment. Severely injured patients stay in intensive care for an average of 11 days. During this time the patient's therapy has to ensure a high quality evidence-based intensive care treatment and simultaneously has to be tailored to the current individual injuries. Because of the fact that the damage control strategy is gaining increasing acceptance, the intensive care unit plays a pivotal role in the critical time between emergency and elective surgery. Therefore a close cooperation between physicians of the intensive care unit and all surgical disciplines involved is essential to reach the aim of therapeutic efforts. After survival of emergency treatment patients with severe trauma should be reintegrated into social and occupational life as soon as possible.

Posttraumatic massive bleeding: a challenging multidisciplinary task

Massive bleeding is a key issue in the treatment of trauma and surgery. It does in fact account for more than 50% of all trauma-related deaths within the first 48 h following hospital admission, and it can significantly raise the mortality rate of any kind of surgery. Despite this great clinical relevance, evidence on the management of massive bleeding is surprisingly scarce, and its treatment is often based on empirical grounds. Successful treatment of massive haemorrhage depends on better understanding of the associated physiological changes as well as on good team work between the different specialists involved in the management of such a complex condition. The aim of this article is to provide an overview of the pathophysiology as well as of current treatment options of such a condition, including the new concept of "damage control resuscitation", which integrates permissive hypotension, haemostatic resuscitation and damage control surgery.

Goal-directed hemostatic resuscitation for massively bleeding patients: the Copenhagen concept

BACKGROUND

Continued hemorrhage remains a major cause of mortality in massively transfused patients, many of whom develop coagulopathy. A review of transfusion practice for these patients at our hospital revealed that a significant proportion received suboptimal transfusion therapy. Survivors had higher platelets count than non-survivors.

METHODS

For massively transfused patients with hemodynamic instability, we introduced the concept of transfusion packages comprising five units of red blood cells, five units of fresh frozen plasma and two units of platelet concentrates. Thrombelastogram analysis was validated for routine laboratory use and implemented in the blood bank for monitoring coagulopathy and guiding transfusion therapy. Anaesthetists at our hospital were trained in functional haemostasis management based on analysis of thrombelastograms.

RESULTS

Intraoperative administration of transfusion packages for patients operated on for a ruptured abdominal aortic aneurysm was associated with a reduction in mortality from 56% to 34% (p = 0.02). When comparing massively transfused patients treated with hemostatic control resuscitation, i.e., transfusion package therapy during hemodynamic instability and thromboelastogram--monitored and guided transfusion therapy, with controls treated in accordance with existing transfusion guidelines, mortality was reduced from 31% to 20% (p = 0.002).

CONCLUSION

The initiative from the blood bank, i.e., transfusion packages for patients with uncontrollable bleeding and based on the thromboelastogram when hemodynamic control is established, has improved the transfusion practice and survival in massively transfused patients at our hospital.

The contemporary role of blood products and components used in trauma resuscitation

INTRODUCTION

There is renewed interest in blood product use for resuscitation stimulated by recent military experience and growing recognition of the limitations of large-volume crystalloid resuscitation.

METHODS

An editorial review of recent reports published by investigators from the United States and Europe is presented. There is little prospective data in this area.

RESULTS

Despite increasing sophistication of trauma care systems, hemorrhage remains the major cause of early death after injury. In patients receiving massive transfusion, defined as 10 or more units of packed red blood cells in the first 24 hours after injury, administration of plasma and platelets in a ratio equivalent to packed red blood cells is becoming more common. There is a clear possibility of time dependent enrollment bias. The early use of multiple types of blood products is stimulated by the recognition of coagulopathy after reinjury which may occur as many as 25% of patients. These patients typically have large-volume tissue injury and are acidotic. Despite early enthusiasm, the value of administration of recombinant factor VIIa is now in question. Another dilemma is monitoring of appropriate component administration to control coagulopathy.

CONCLUSION

In patients requiring large volumes of blood products or displaying coagulopathy after injury, it appears that early and aggressive administration of blood component therapy may actually reduce the aggregate amount of blood required. If recombinant factor VIIa is given, it should be utilized in the fully resuscitated patient. Thrombelastography is seeing increased application for real-time assessment of coagulation changes after injury and directed replacement of components of the clotting mechanism.

The incidence and significance of accidental hypothermia in major trauma--a prospective observational study

BACKGROUND

Serious sequelae have been associated with injured patients who are hypothermic (<35°C) including coagulopathy, acidosis, decreased myocardial contractility and risk of mortality.

AIM

Establish the incidence of accidental hypothermia in major trauma patients and identify causative factors.

METHOD

Prospective identification and subsequent review of 732 medical records of major trauma patients presenting to an Adult Major Trauma Centre was undertaken between January and December 2008. Multivariate analysis was performed using logistic regression. Significant and clinically relevant variables from univariate analysis were entered into multivariate models to evaluate determinants for hypothermia and for death. Goodness of fit was determined with the use of the Hosmer-Lemeshow statistic.

MAIN RESULTS

Overall mortality was 9.15%. The incidence of hypothermia was 13.25%. The mortality of patients with hypothermia was 29.9% with a threefold independent risk of death: OR (CI 95%) 3.44 (1.48-7.99), P = 0.04. Independent determinants for hypothermia were pre-hospital intubation: OR (CI 95%) 5.18 (2.77-9.71), P < 0.001, Injury Severity Score (ISS): 1.04 (1.01-1.06), P = 0.01, Arrival Systolic Blood Pressure (ASBP) < 100 mm Hg: 3.04 (1.24-7.44), P = 0.02, and winter time: 1.84 (1.06-3.21), P = 0.03. Of the 87 hypothermic patients who had repeat temperatures recorded in the Emergency Department, 77 (88.51%) patients had a temperature greater than the recorded arrival temperature. There was no change in recorded temperature for four (4.60%) patients, whereas six (6.90%) patients were colder at Emergency Department discharge.

CONCLUSION

Seriously injured patients with accidental hypothermia have a higher mortality independent of measured risk factors. For patients with multiple injuries a coordinated effort by paramedics, nurses and doctors is required to focus efforts toward early resolution of hypothermia aiming to achieve a temperature >35 °C.

Massive transfusion and blood product use in the pediatric trauma patient

Hemorrhagic shock in the pediatric trauma patient is an uncommon but fundamental problem for the treating clinician. Current management of hemorrhagic shock involves initial resuscitation with crystalloid fluids followed by infusion of blood components as necessary. In management of the adult trauma patient, many institutions have implemented massive transfusion protocols to guide transfusion in situations requiring or anticipating the use of greater than 10 U of packed red blood cells. In the pediatric population, guidelines for massive transfusion are vague or nonexistent. Adult trauma transfusion protocols can be applied to children until a pediatric protocol is validated. Here, we attempt to identify certain principles of transfusion therapy specific to pediatric trauma and outline a sample pediatric massive transfusion protocol that may be used to guide resuscitation. Also, adjuncts to transfusion, such as colloid fluids, other plasma expanders or hemoglobin substitutes, and recombinant activated factor VII, are discussed.

Recombinant activated factor VII attenuates major arterial bleeding in noncoagulopathic rabbits

BACKGROUND AND OBJECTIVE

Recombinant activated factor VII (rFVIIa), which is used off-label as an adjuvant therapy for uncontrolled and life-threatening bleeding, might also attenuate intractable bleeding related to macrovascular arterial lesions. Here we evaluated the efficacy of rFVIIa in sealing a large arterial wound in haemostatically competent rabbits.

METHODS

Sixty male New Zealand rabbits were randomly divided into vehicle control and 80 and 200 μg kg⁻¹ rFVIIa groups (n = 20 animals each). A standardized wound of the isolated right carotid artery was made in all rabbits with an 18-G catheter. Bleeding, which was limited by mild compression, was assessed every minute. At 5 min, an intravenous bolus of vehicle or human rFVIIa was given and the animals were further observed for 1 h. Efficacy was assessed from the bleeding duration and blood mass lost. Statistical significance was defined as P less than 0.05. All investigators were blinded to the treatment the animals received.

RESULTS

The bleeding duration and blood mass lost were significantly reduced in both rFVIIa dosage groups as compared with the vehicle control group. For the vehicle, 80 and 200 μg kg⁻¹ rFVIIa groups, the median bleeding durations were 56 min (range 7-60 min), 15 min (range 5-60 min) and 10 min (range 5-60 min), respectively; and the median blood mass losses were 22.5 g (range 1-58 g), 12 g (range 0-36 g) and 5 g (range 0-31 g), respectively. The prothrombin time was shorter in the rFVIIa groups. Visual inspection of the carotid artery and microscopic analysis of the liver and kidney revealed neither gross thrombi nor entrapped microthrombi in any rabbit.

CONCLUSION

Recombinant FVIIa at 80 or 200 μg kg⁻¹ promoted the sealing of a large and slightly compressed arterial wound in rabbits. These results suggest a potential role for the drug in the management of massive bleeds due to an arterial lesion when surgical intervention is not immediately and readily available. Safety should remain a matter of concern.

All bleeding stops: how we can help

Rossaint and colleagues provide the critical care community with a comprehensive review of evidence-based data in an updated European guideline on management of bleeding following major trauma. In addition to reevaluating and grading recommendations carried forward from their previous work, they present new recommendations in areas such as coagulation support and monitoring, tourniquet usage, calcium, and desmopressin. Many of the recommendations are appropriately broad enough to promote the use of clinical judgment in the application of the guidelines.