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Mathew SK, Le TD, Pusateri AE, Pinto DN, Carney BC, McLawhorn MM, Tejiram S, Travis TE, Moffatt LT, Shupp JW. Plasma Inclusive Resuscitation Is Not Associated With Coagulation Profile Changes in Burn Patients. J Surg Res 2024; 303:233-240. [PMID: 39378792 DOI: 10.1016/j.jss.2024.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 08/01/2024] [Accepted: 09/02/2024] [Indexed: 10/10/2024]
Abstract
INTRODUCTION Dynamically titrated crystalloids are the standard of care for burn shock resuscitation. There are theoretical concerns that the adjunctive use of allogeneic plasma may perturb the patient's coagulation and inflammation status deleteriously. It was hypothesized that plasma-inclusive resuscitation (PIR) would not be associated with prothrombotic changes relative to baseline after thermal injury. METHODS Patients admitted to a regional burn center who were treated with PIR as part of their burn resuscitation were enrolled. Whole blood samples were analyzed prospectively via rapid thromboelastography and rotational thromboelastometry to assess for coagulopathy at four time points throughout their acute burn resuscitation. The mixed-effect model for repeated measures followed by Tukey's post hoc test for comparisons was used to examine group differences. RESULTS There were 35 patients in the analysis. Most were male (74.3%) with a median age of 43 y (32-55), concomitant inhalation injury of 28.6%, total body surface area burn size of 34% (27%-48.5%), and the overall mortality of the cohort was 28.6%. There were no transfusion reactions or thrombotic events. There were no differences in thromboelastography or rotational thromboelastometry parameters overall or when stratified by mortality, total body surface area burn, and inhalation injury. There were no significant differences between the fibrinolytic phenotypes over time. CONCLUSIONS Data suggest that PIR was not associated with prothrombotic or lytic changes in burn patients relative to baseline. Further research is needed to confirm these findings and evaluate efficacy of PIR in acute burn resuscitation.
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Affiliation(s)
- Shane K Mathew
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia
| | - Tuan D Le
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia
| | | | - Desiree N Pinto
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia
| | - Bonnie C Carney
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Biochemistry, Georgetown University School of Medicine, Washington, District of Columbia
| | - Melissa M McLawhorn
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia
| | - Shawn Tejiram
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; The Burn Center, MedStar Washington Hospital Center, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Taryn E Travis
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; The Burn Center, MedStar Washington Hospital Center, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Lauren T Moffatt
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Biochemistry, Georgetown University School of Medicine, Washington, District of Columbia
| | - Jeffrey W Shupp
- Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, District of Columbia; The Burn Center, MedStar Washington Hospital Center, Washington, District of Columbia; Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Department of Biochemistry, Georgetown University School of Medicine, Washington, District of Columbia; Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia.
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Schwietring J, Wähnert D, Scholl LS, Thies KC. [Prehospital blood transfusion : Opportunities and challenges for the German emergency medical services]. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01463-9. [PMID: 39356309 DOI: 10.1007/s00101-024-01463-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/18/2024] [Indexed: 10/03/2024]
Abstract
BACKGROUND Exsanguination is the leading cause of preventable death in severe trauma. Immediate hemorrhage control and transfusion of blood products are critical to maintain oxygen delivery and address trauma-induced coagulopathy. While prehospital blood product transfusion (PHBT) is established in neighboring countries, the fragmented configuration of Germany's emergency medical service (EMS) infrastructure has delayed the adoption of widespread PHBT programmes. This review aims to provide an updated perspective on the evolution, international practices and research needs of PHBT within the German context. METHODS This narrative review is based on a PubMed search using the search terms "prehospital" and "blood*". From an initial 4738 articles, 333 were directly related to PHBT and were subjected to further detailed examination. The literature, including referenced studies, was categorized into areas such as history, rationale, international practices, and evidence, and analyzed for quality. RESULTS The benefit of early blood transfusion in major trauma has been established since WW1, explaining the efforts to initiate this lifesaving intervention as early as possible in the care pathway, including the prehospital field. Recent randomized trials have faced design and recruitment challenges, reflecting the complexity of the research question. These trials have yielded inconclusive results regarding the survival benefits of PHBT in civilian settings. This scenario raises doubts about the capability of randomized trials to resolve questions concerning survival advantages. Despite these difficulties, there is a discernible trend indicating potential improvements in patient outcomes. In Germany, the incidence of trauma-associated shock stands at 38 per 100,000 individuals per year. It is estimated that between 300 and 1800 patients annually possibly benefit from PHBT. CONCLUSION Prehospital Blood Transfusion appears to be promising but identifying patient groups most likely to benefit as well as the most suitable blood products remain unresolved issues. In Germany PHBT programs are not yet widely established. Paradoxically, this situation, paired with the extensive German Trauma Registry, provides a prime opportunity for comprehensive prospective cohort studies, addressing the balance between PHBT benefits, logistical feasibility, and implementation strategies. Such studies are essential for establishing guidelines and integrating PHBT efficiently into German trauma care protocols.
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Affiliation(s)
- Jens Schwietring
- Ruhr-Universität Bochum, Medizinische Fakultät, Bochum, Deutschland.
- ADAC Luftrettung gGmbH, Hansastr. 19, 80686, München, Deutschland.
| | - Dirk Wähnert
- Universität Bielefeld, Medizinische Fakultät und Universitätsklinikum OWL, Ev. Klinikum Bethel, Universitätsklinik für Unfallchirurgie und Orthopädie, Bielefeld, Deutschland
| | | | - Karl-Christian Thies
- Universität Bielefeld, Medizinische Fakultät und Universitätsklinikum OWL, Ev. Klinikum Bethel, Universitätsklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin, Transfusionsmedizin und Schmerztherapie, Bielefeld, Deutschland
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Shen A, Di Meo B, Perez IA, Hashim Y, Ko A, Margulies DR, Klapper EB, Barmparas G. Reconsidering Fresh Frozen Plasma Availability to Reduce Blood Product Waste During Massive Transfusion Events in Trauma. Am Surg 2024; 90:2530-2533. [PMID: 38658467 DOI: 10.1177/00031348241248811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Within component therapy of massive transfusion protocol (MTP) in trauma, thawed plasma is particularly susceptible to expiring without use given its short 5-day shelf life. Optimizing the number of thawed products without compromising safety is important for hospital resource management. The goal is to examine thawed plasma utilization rates in trauma MTP events and optimize the MTP cooler content at our Level I trauma center. METHODS Trauma MTP activations from 01/2019 to 12/2022 were retrospectively reviewed. During the study period, blood products were distributed in a 12:12:1 ratio of packed red blood cells (pRBC): plasma: platelets per cooler, with up to 4 additional units of low-titer, group O whole blood (LTOWB) available. The primary measure was percent return of unused, thawed plasma. RESULTS There were 367 trauma MTP activations with a median (IQR) activation call-to-first cooler delivery time of 8 (6-10) minutes. 73.0% of thawed plasma was returned to the blood bank unused. In one third of MTP activations, all dispensed plasma was returned. The majority (74.1%) of patients required 6 or fewer units of plasma. In 81.5% of activations, 10 or fewer units of plasma and 10 or fewer units of pRBC were used. DISCUSSION The majority of trauma MTP requirements may be accommodated with a reduced cooler content of 6 units pRBC, 6 units plasma, and 1 pheresis platelets, buffered by up to 4 units LTOWB (approximates 4 units of pRBC/4 units plasma), in conjunction with a sub-10min cooler delivery time. Follow-up longitudinal studies are needed.
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Affiliation(s)
- Aricia Shen
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brent Di Meo
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ingrid A Perez
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yassar Hashim
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ara Ko
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ellen B Klapper
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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von Olnhausen O, Wladis A, Bäckström D. Incidence and characteristics of prehospital fatalities from haemorrhage in Sweden: a nationwide observational study. Scand J Trauma Resusc Emerg Med 2024; 32:96. [PMID: 39327632 PMCID: PMC11426000 DOI: 10.1186/s13049-024-01269-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 09/16/2024] [Indexed: 09/28/2024] Open
Abstract
BACKGROUND Haemorrhage is a leading cause of preventable mortality in high-income countries and emergency management presents unique challenges in the prehospital setting. The study aimed to determine incidence and characteristics of fatalities from prehospital haemorrhage in Sweden. METHODS A nationwide retrospective cohort study 2012-2021 was conducted using data from the Swedish National Board of Health and Welfare. Prehospital fatality from haemorrhage was defined as a cause of death related to haemorrhage (Appendix 1) without a hospital admission on the same day. Primary outcome was age-standardized mortality rate per 100,000 inhabitants. RESULTS A total of 9801 prehospital fatalities from haemorrhage were identified. Annual age-standardized mortality rate decreased from 10.97 to 8.18 per 100,000 population (coefficient = - 0.28, r2 = 0.85, p = < 0.001). Trauma was the most common cause (3512, 35.83%) with intentional self-harm (X60-X84), transport accidents (V01-V99) and assault (X85-Y09) being the most common mechanisms of injury. Traumatic fatalities were younger and a larger proportion were male compared to non-traumatic causes (p < 0.001). Overall median Charlson Comorbidity Index (Quan) was 0 [0-2] with a lower index noted for traumatic causes (p < 0.001). Trauma resulted in a median of 26.1 [3.65-49.22] years of life lost per patient compared to 0 [0-3.65] for non-traumatic causes (p < 0.001). Regional variations in mortality rate were observed with lower population density correlating with higher mortality rate (ρ = - 0.64, p = 0.002). CONCLUSIONS Prehospital mortality from haemorrhage decreased between 2012 and 2021. Trauma was the most common cause which resulted in many years of life lost in a population with a low burden of comorbidities. There were considerable regional differences with low population density associated with higher mortality rate from prehospital haemorrhage.
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Affiliation(s)
- Oliver von Olnhausen
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Wladis
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Denise Bäckström
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
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Hargrave E, Alexander R, Leeper CM, Leonard JC, Josephson CD, Steiner ME, Spinella PC, Muszynski JA. Massive Transfusion in Pediatric Patients on Extracorporeal Membrane Oxygenation: A Secondary Analysis of the Massive Transfusion in Children (MATIC) Study. ASAIO J 2024; 70:803-807. [PMID: 38626783 DOI: 10.1097/mat.0000000000002212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2024] Open
Abstract
Few data describe pediatric patients who receive massive transfusion for life-threatening hemorrhage (LTH) while on extracorporeal membrane oxygenation (ECMO). We present a retrospective secondary analysis of a multicenter prospective observational study to describe resource utilization and mortality in pediatric patients with LTH while on ECMO. Children who were on ECMO during an LTH were compared to children with LTH who were not on ECMO. Primary outcomes were volumes of blood products administered and 28 day mortality. Comparisons were assessed by two-sided Fisher's exact test or Wilcoxon rank sum test. A total of 449 children, including 36 on ECMO, were included. Compared to those not on ECMO, children on ECMO received a higher volume of blood products (110 [50-223] vs . 59 [28-113]) ml/kg, p = 0.002) and were more likely to receive antifibrinolytic therapy (39% vs . 10%, p < 0.001). Blood product ratios were similar. Extracorporeal membrane oxygenation patients had higher 28 day mortality (64% vs. 35%, p = 0.001), although 24 hour mortality was similar (17% vs . 23%, p = 0.5). In conclusion, children on ECMO with LTH experience high resource utilization and 28 day mortality. Studies are needed to identify children at risk for LTH and to evaluate ECMO-specific treatment strategies.
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Affiliation(s)
- Emily Hargrave
- Divisions of Pediatric Critical Care Medicine and Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Robin Alexander
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, Ohio
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Christine M Leeper
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Julie C Leonard
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Casandra D Josephson
- Department of Oncology, Johns Hopkins University School of Medicine, Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marie E Steiner
- Divisions of Pediatric Critical Care Medicine and Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Philip C Spinella
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
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Fujiwara G, Okada Y, Ishii W, Echigo T, Shiomi N, Ohtsuru S. High Fresh Frozen Plasma to Red Blood Cell Ratio and Survival Outcomes in Blunt Trauma. JAMA Surg 2024:2822573. [PMID: 39167374 PMCID: PMC11339704 DOI: 10.1001/jamasurg.2024.3097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 06/11/2024] [Indexed: 08/23/2024]
Abstract
Importance Current trauma-care protocols advocate early administration of fresh frozen plasma (FFP) in a ratio close to 1:1 with red blood cells (RBCs) to manage trauma-induced coagulopathy in patients with severe blunt trauma. However, the benefits of a higher FFP to RBC ratio have not yet been established. Objective To investigate the effectiveness of a high FFP to RBC transfusion ratio in the treatment of severe blunt trauma and explore the nonlinear relationship between the ratio of blood products used and patient outcomes. Design, Setting, and Participants This was a multicenter cohort study retrospectively analyzing data from the Japan Trauma Data Bank, including adult patients with severe blunt trauma without severe head injury (Injury Severity Score ≥16 and head Abbreviated Injury Scale <3) between 2019 and 2022. Exposures Patients were categorized into 2 groups based on the ratio of FFP to RBC: the high-FFP group (ratio >1) and the low-FFP group (ratio ≤1). Main Outcomes and Measures All-cause in-hospital mortality was the primary outcome. Additionally, the occurrence of transfusion-related adverse events was evaluated. Results Among the 1954 patients (median [IQR] age, 61 [41-77] years; 1243 male [63.6%]) analyzed, 976 (49.9%) had a high FFP to RBC ratio. Results from logistic regression, weighted by inverse probability treatment weighting, demonstrated an association between the group with a high-FFP ratio and lower in-hospital mortality (odds ratio, 0.73; 95% CI, 0.56-0.93) compared with a low-FFP ratio. Nonlinear trends were noted, suggesting a potential ceiling effect on transfusion benefits. Conclusions and Relevance In this cohort study, a high FFP to RBC ratio was associated with favorable survival in patients with severe blunt trauma. These outcomes highlight the importance of revising the current transfusion protocols to incorporate a high FFP to RBC ratio, warranting further research on optimal patient treatment.
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Affiliation(s)
- Gaku Fujiwara
- Department of Management of Technology and Intellectual Property, School of Public Health, Kyoto University, Kyoto, Japan
- Department of Pharmacoepidemiology, School of Public Health, Kyoto University, Kyoto, Japan
- Department of Neurosurgery, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yohei Okada
- Department of Preventive Services, School of Public Health, Kyoto University. Yoshidahonmachi, Sakyo-ku, Kyoto, Japan
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Wataru Ishii
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Tadashi Echigo
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Shiga, Japan
| | - Naoto Shiomi
- Department of Critical and Intensive Care Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Turnbull C, Clegg L, Santhakumar A, Micalos PS. Blood Product Administration in the Prehospital Setting: A Scoping Review. PREHOSP EMERG CARE 2024:1-14. [PMID: 39159401 DOI: 10.1080/10903127.2024.2386007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 07/09/2024] [Accepted: 07/16/2024] [Indexed: 08/21/2024]
Abstract
OBJECTIVES Implementing prehospital blood products for treating hemorrhagic shock has been utilized globally in military and civilian settings. This review aims to compare various guidelines for using blood products, including the types of blood products, injuries, biomarkers (hemodynamic measurement) to indicate use, associated treatments and risks, and the logistical concerns of storage and wastage in the prehospital setting. Furthermore, it explores whether prehospital blood transfusions are beneficial and a safe treatment option. METHODS Data were collected using a systematic search and screening process of online databases CINAHL, Medline, and Scopus, as well as by creating a PRISMA flow diagram to screen articles using inclusion and exclusion criteria. Forty-five articles were screened, with twenty-five excluded, resulting in twenty articles in this scoping review. RESULTS The most frequently used blood product used was red blood cells, with twelve studies using either red blood cells alone or in combination with other products. Indications for blood use varied across services, but all aimed to address hemodynamic instability as a primary indication for blood transfusion. Eleven studies recorded no adverse reactions. Only one study reported chills and shivers; however, it was unclear if blood products were the cause. Nine studies avoided logistical issues of storage and wastage to create a feasible rotation system. CONCLUSIONS Prehospital blood was used in medical, trauma, and maternity-related hemorrhage. Many types of blood products are in use, ranging from component therapy to whole blood, with each protocol having different indications of use and treatment guidelines aimed at improving hemodynamic stability.
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Affiliation(s)
- Caitlin Turnbull
- School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Port Macquarie, New South Wales, Australia
| | - Lisa Clegg
- School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Port Macquarie, New South Wales, Australia
| | - Abishek Santhakumar
- School of Dentistry and Medical Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Peter S Micalos
- School of Dentistry and Medical Sciences, Charles Sturt University, Port Macquarie, New South Wales, Australia
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Dion PM, Nolan B, Funk C, Laverty C, Scott J, Miller D, Beckett A. Blood far forward: A cross-sectional analysis of prehospital transfusion practices in the Canadian Armed Forces. Injury 2024:111771. [PMID: 39122619 DOI: 10.1016/j.injury.2024.111771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 07/29/2024] [Accepted: 07/31/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Canadian Armed Forces (CAF) operate in environments that challenge patient care, especially trauma. Military personnel often find themselves in remote settings without conventional healthcare facilities. Treating traumatic injuries, particularly hemorrhagic shock, often necessitates prehospital blood transfusion. This study aims to present an overview of the current CAF prehospital transfusion practices. Furthermore, the study compared current and developing protocols against expert-recommended guidelines. METHODS A cross-sectional survey design was employed to describe and compare CAF prehospital blood transfusion practices and protocols against expert recommendations. Topics included protocols, equipment, and procedures. An online survey targeted medical leadership and providers within CAF, with data collected from August 15 to December 15, 2023. Results were summarized descriptively. This study received approval from the Unity Health Toronto Research Ethics Board (REB 23-087). RESULTS Units and teams with prehospital blood transfusion capabilities were contacted, achieving a 100 % response rate. Within CAF, Canadian Special Operations Forces Command (CANSOFCOM), Mobile Surgical Resuscitation Team (MSRT), and Canadian Medical Emergency Response Team (CMERT) possess these capabilities, established between 2013 and 2018. These programs are crucial for military operations. CAF has access to standard blood components, cold Leuko-Reduced Whole Blood (LrWB), and factor concentrates from Canadian Blood Services (CBS), available for both domestic and international missions given adequate planning and favorable conditions. Key findings indicate high adherence to recommended practices, some variability in the transfusion process, and potential benefits of standardizing prehospital transfusion practices. CONCLUSIONS This study provided insights into CAF's implementation of prehospital transfusion practices, highlighting high adherence to national expert recommendations and the importance of structured protocols in military prehospital trauma management. IMPLICATIONS OF KEY FINDINGS CAF's approach and adoption of prehospital transfusion protocols lay a strong foundation for managing trauma patients in remote settings and for expanding prehospital transfusion capabilities across CFHS deployed assets. Further research is needed to advance military trauma care by adapting prehospital blood transfusion to dynamic tactical landscapes and evolving technologies.
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Affiliation(s)
- Pierre-Marc Dion
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, Ontario, Canada.
| | - Brodie Nolan
- Department of Emergency Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Ornge, Mississauga, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Christopher Funk
- Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, Ontario, Canada
| | - Colin Laverty
- Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, Ontario, Canada
| | - Jeffrey Scott
- Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, Ontario, Canada
| | - Damien Miller
- Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, Ontario, Canada
| | - Andrew Beckett
- Royal Canadian Medical Service, Canadian Armed Forces, Ottawa, Ontario, Canada; Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada; Department of Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Lawrence-Mills S, Santoro F, Foster A, Talbot CT, Tinson E, Humm K. Retrospective evaluation of plasma transfusions in dogs undergoing general anaesthesia: 85 cases (2017-2021). Vet Anaesth Analg 2024:S1467-2987(24)00129-6. [PMID: 39395873 DOI: 10.1016/j.vaa.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 05/27/2024] [Accepted: 07/08/2024] [Indexed: 10/14/2024]
Abstract
OBJECTIVE To describe the use of plasma transfusion in anaesthetized dogs, specifically the triggers for use, the population administered plasma, reported adverse events and human errors associated with transfusion. STUDY DESIGN Retrospective observational study. ANIMALS A total of 85 client-owned dogs. METHODS A search of electronic transfusion and anaesthetic records at a university teaching hospital was performed to identify dogs administered plasma during the study period (January 2017 to June 2021). Data collected included signalment, surgical procedure, intraoperative triggers for transfusion, the type of plasma, rate of transfusion and the presence of transfusion reactions, human errors or deviation from transfusion guidelines. RESULTS During this period, 85 dogs were administered plasma. Sepsis was diagnosed in 49/85 (58%) dogs, with 42/85 (49%) animals undergoing surgery for septic peritonitis. Perianaesthetic hypotension contributed to the decision to administer plasma in 67/85 (79%) dogs. In 33/85 (39%) dogs, hypotension was the only reason for transfusion, while 31/85 (36%) had other influencing factors, most commonly hypoproteinaemia. Fresh frozen plasma was administered in 95% of cases. Only 31% of transfusions were started at a slower 'test dose' rate and 79% of dogs administered boluses of plasma. No definite, probable or possible transfusion reactions were identified using current veterinary guidelines. CONCLUSIONS AND CLINICAL RELEVANCE Plasma transfusions were commonly administered to dogs presenting with sepsis for haemodynamic optimization. Clinicians often chose to bolus plasma instead of initiating transfusions at the recommended initial slow starting rate. No transfusion reactions were identified; however, some reactions may have been masked by the effects of general anaesthesia and/or have been difficult to recognize in this critically ill canine population.
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Affiliation(s)
| | - Francesco Santoro
- Clinical Science and Services, The Royal Veterinary College, Radlett, UK
| | | | - Charles T Talbot
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, USA
| | - Erica Tinson
- Clinical Science and Services, The Royal Veterinary College, Radlett, UK
| | - Karen Humm
- Clinical Science and Services, The Royal Veterinary College, Radlett, UK
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Liggett MR, Lashley S, Gill NP, Scholtens DM, Dawood ZS, Alam HB. Plasma therapy for traumatic brain injury: Rationale for a prospective randomized trial. Transfusion 2024; 64:1362-1371. [PMID: 38940059 DOI: 10.1111/trf.17928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/08/2024] [Accepted: 02/16/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Marjorie R Liggett
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sharnia Lashley
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nathan P Gill
- Department of Preventative Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Denise M Scholtens
- Department of Preventative Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Zaiba Shafik Dawood
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Hasan B Alam
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Cannon JW, Gruen DS, Zamora R, Brostoff N, Hurst K, Harn JH, El-Dehaibi F, Geng Z, Namas R, Sperry JL, Holcomb JB, Cotton BA, Nam JJ, Underwood S, Schreiber MA, Chung KK, Batchinsky AI, Cancio LC, Benjamin AJ, Fox EE, Chang SC, Cap AP, Vodovotz Y. Digital twin mathematical models suggest individualized hemorrhagic shock resuscitation strategies. COMMUNICATIONS MEDICINE 2024; 4:113. [PMID: 38867000 PMCID: PMC11169363 DOI: 10.1038/s43856-024-00535-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 05/29/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND Optimizing resuscitation to reduce inflammation and organ dysfunction following human trauma-associated hemorrhagic shock is a major clinical hurdle. This is limited by the short duration of pre-clinical studies and the sparsity of early data in the clinical setting. METHODS We sought to bridge this gap by linking preclinical data in a porcine model with clinical data from patients from the Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) study via a three-compartment ordinary differential equation model of inflammation and coagulation. RESULTS The mathematical model accurately predicts physiologic, inflammatory, and laboratory measures in both the porcine model and patients, as well as the outcome and time of death in the PROMMTT cohort. Model simulation suggests that resuscitation with plasma and red blood cells outperformed resuscitation with crystalloid or plasma alone, and that earlier plasma resuscitation reduced injury severity and increased survival time. CONCLUSIONS This workflow may serve as a translational bridge from pre-clinical to clinical studies in trauma-associated hemorrhagic shock and other complex disease settings.
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Affiliation(s)
- Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA.
| | - Danielle S Gruen
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA
| | - Noah Brostoff
- Immunetrics, now wholly owned by Simulations Plus, Pittsburgh, PA, 15219, USA
| | - Kelly Hurst
- Immunetrics, now wholly owned by Simulations Plus, Pittsburgh, PA, 15219, USA
| | - John H Harn
- Immunetrics, now wholly owned by Simulations Plus, Pittsburgh, PA, 15219, USA
| | - Fayten El-Dehaibi
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Zhi Geng
- Division of Traumatology, Surgical Critical Care & Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rami Namas
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
| | - John B Holcomb
- Department of Surgery, University of Alabama, Birmingham, AL, 35233, USA
| | - Bryan A Cotton
- Division of Acute Care Surgery, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Jason J Nam
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Samantha Underwood
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, Oregon Health & Science University, Portland, OR, 97239, USA
| | | | - Andriy I Batchinsky
- Autonomous Reanimation and Evacuation (AREVA) Research and Innovation Center, San Antonio, TX, 78235, USA
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, TX, 78234, USA
| | - Andrew J Benjamin
- Trauma and Acute Care Surgery, Department of Surgery, The University of Chicago, Chicago, IL, 60637, USA
| | - Erin E Fox
- Division of Acute Care Surgery, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Steven C Chang
- Immunetrics, now wholly owned by Simulations Plus, Pittsburgh, PA, 15219, USA
| | - Andrew P Cap
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, 20814, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Pittsburgh Trauma Research Center, Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, 15219, USA
- Center for Systems Immunology, University of Pittsburgh, Pittsburgh, PA, 15213, USA
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Apelseth TO, Raza S, Callum J, Ipe T, Blackwood B, Akhtar A, Hess JR, Marks DC, Brown B, Delaney M, Wendel S, Stanworth SJ. A review and analysis of outcomes in randomized clinical trials of plasma transfusion in patients with bleeding or for the prevention of bleeding: The BEST collaborative study. Transfusion 2024; 64:1116-1131. [PMID: 38623793 DOI: 10.1111/trf.17835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Previous systematic reviews have revealed an inconsistency of outcome definitions as a major barrier in providing evidence-based guidance for the use of plasma transfusion to prevent or treat bleeding. We reviewed and analyzed outcomes in randomized controlled trials (RCTs) to provide a methodology for describing and classifying outcomes. STUDY DESIGN AND METHODS RCTs involving transfusion of plasma published after 2000 were identified from a prior review (Yang 2012) and combined with an updated systematic literature search of multiple databases (July 1, 2011 to January 17, 2023). Inclusion of publications, data extraction, and risk of bias assessments were performed in duplicate. (PROSPERO registration number is: CRD42020158581). RESULTS In total, 5579 citations were identified in the new systematic search and 22 were included. Six additional trials were identified from the previous review, resulting in a total of 28 trials: 23 therapeutic and five prophylactic studies. An increasing number of studies in the setting of major bleeding such as in cardiovascular surgery and trauma were identified. Eighty-seven outcomes were reported with a mean of 11 (min-max. 4-32) per study. There was substantial variation in outcomes used with a preponderance of surrogate measures for clinical effect such as laboratory parameters and blood usage. CONCLUSION There is an expanding literature on plasma transfusion to inform guidelines. However, considerable heterogeneity of reported outcomes constrains comparisons. A core outcome set should be developed for plasma transfusion studies. Standardization of outcomes will motivate better study design, facilitate comparison, and improve clinical relevance for future trials of plasma transfusion.
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Affiliation(s)
- Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, University of Bergen, Bergen, Norway
- Norwegian Armed Forces Joint Medical Services, Oslo, Norway
| | - Sheharyar Raza
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Canada
| | - Tina Ipe
- Our Blood Institute, Oklahoma City, Oklahoma, USA
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | | | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Denese C Marks
- Research and Development, Australian Red Cross Lifeblood, Sydney, Australia
| | - Bethany Brown
- American Red Cross, Medical and Scientific Office, Washington, DC, USA
| | | | | | - Simon J Stanworth
- NHSBT, Oxford University Hospitals NHS Trust; Blood Transfusion Research Unit (BTRU), University of Oxford, Oxford, UK
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13
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Schoenfeld DW, Rosen CL, Harris T, Thomas SH. Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis. Acad Emerg Med 2024; 31:590-598. [PMID: 38517320 DOI: 10.1111/acem.14882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/06/2024] [Accepted: 01/10/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products. METHOD The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified. RESULTS In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19). CONCLUSIONS Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.
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Affiliation(s)
- David W Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Carlo L Rosen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Tim Harris
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
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14
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Campbell K, Scanlon E, Bhanot K, Harper F, Naumann DN. 4A after access: a new mnemonic to aid timely administration of IV/IO treatment in trauma patients. BMJ Mil Health 2024; 170:193-195. [PMID: 37696654 DOI: 10.1136/military-2023-002463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/21/2023] [Indexed: 09/13/2023]
Abstract
Administration of medication is a well-established part of prehospital trauma care. Guidance varies on the types of recommended medications and when they should be administered. Mnemonics have become commonplace in prehospital medicine to facilitate recall and retention. However, there is no comprehensive aid for the administration of medication in trauma patients. We propose a new mnemonic for the delivery of relevant intravenous or intraosseous medications in trauma patients. A '4A after Access' approach should enhance memory recall for the efficient provision of patient care. These 4As are: antifibrinolysis, analgesia, antiemesis and antibiotics. This mnemonic is designed to be used as an optional aide memoire in conjunction with existing treatment algorithms in the military prehospital setting.
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Affiliation(s)
- Kieran Campbell
- Academic Department of General Practice, Royal Centre for Defence Medicine, Birmingham, UK
| | - E Scanlon
- Academic Department of General Practice, Royal Centre for Defence Medicine, Birmingham, UK
| | - K Bhanot
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - F Harper
- Academic Department of General Practice, Royal Centre for Defence Medicine, Birmingham, UK
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
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15
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Mitra B, Talarico CS, Olaussen A, Anderson D, Meadley B. Blood lactate after pre-hospital blood transfusion for major trauma by helicopter emergency medical services. Vox Sang 2024; 119:460-466. [PMID: 38357735 DOI: 10.1111/vox.13598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND OBJECTIVES The appropriate use of blood components is essential for ethical use of a precious, donated product. The aim of this study was to report in-hospital red blood cell (RBC) transfusion after pre-hospital transfusion by helicopter emergency medical service paramedics. A secondary aim was to assess the potential for venous blood lactate to predict ongoing transfusion. MATERIALS AND METHODS All patients who received RBC in air ambulance were transported to a single adult major trauma centre, had venous blood lactate measured on arrival and did not die before ability to transfuse RBC were included. The association of venous blood lactate with ongoing RBC transfusion was assessed using multi-variable logistic regression analysis and reported using adjusted odds ratios (aOR). The discriminative ability of venous blood lactate was assessed using area under receiver operating characteristics curve (AUROC). RESULTS From 1 January 2016 to 15 May 2019, there were 165 eligible patients, and 128 patients were included. In-hospital transfusion occurred in 97 (75.8%) of patients. Blood lactate was associated with ongoing RBC transfusion (aOR: 2.00; 95% confidence interval [CI]: 1.36-2.94). Blood lactate provided acceptable discriminative ability for ongoing transfusion (AUROC: 0.78; 95% CI: 0.70-0.86). CONCLUSIONS After excluding patients with early deaths, a quarter of those who had prehospital RBC transfusion had no further transfusion in hospital. Venous blood lactate appears to provide value in identifying such patients. Lactate levels after pre-hospital transfusion could be used as a biomarker for transfusion requirement after trauma.
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Affiliation(s)
- Biswadev Mitra
- Alfred Health Emergency Service, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Carly S Talarico
- Alfred Health Emergency Service, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alexander Olaussen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - David Anderson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Ben Meadley
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
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16
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Mould-Millman NK, Wogu AF, Fosdick BK, Dixon JM, Beaty BL, Bhaumik S, Lategan HJ, Stassen W, Schauer SG, Steyn E, Verster J, Wylie C, de Vries S, Jamison M, Kohlbrenner M, Mayet M, Hodsdon L, Wagner L, Snyders LO, Doubell K, Lourens D, Bebarta VS. Association of freeze-dried plasma with 24-h mortality among trauma patients at risk for hemorrhage. Transfusion 2024; 64 Suppl 2:S155-S166. [PMID: 38501905 DOI: 10.1111/trf.17792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Blood products form the cornerstone of contemporary hemorrhage control but are limited resources. Freeze-dried plasma (FDP), which contains coagulation factors, is a promising adjunct in hemostatic resuscitation. We explore the association between FDP alone or in combination with other blood products on 24-h mortality. STUDY DESIGN AND METHODS This is a secondary data analysis from a cross-sectional prospective observational multicenter study of adult trauma patients in the Western Cape of South Africa. We compare mortality among trauma patients at risk of hemorrhage in three treatment groups: Blood Products only, FDP + Blood Products, and FDP only. We apply inverse probability of treatment weighting and fit a multivariable Cox proportional hazards model to assess the hazard of 24-h mortality. RESULTS Four hundred and forty-eight patients were included, and 55 (12.2%) died within 24 h of hospital arrival. Compared to the Blood Products only group, we found no difference in 24-h mortality for the FDP + Blood Product group (p = .40) and a lower hazard of death for the FDP only group (hazard = 0.38; 95% CI, 0.15-1.00; p = .05). However, sensitivity analyses showed no difference in 24-h mortality across treatments in subgroups with moderate and severe shock, early blood product administration, and accounting for immortal time bias. CONCLUSION We found insufficient evidence to conclude there is a difference in relative 24-h mortality among trauma patients at risk for hemorrhage who received FDP alone, blood products alone, or blood products with FDP. There may be an adjunctive role for FDP in hemorrhagic shock resuscitation in settings with significantly restricted access to blood products.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adane F Wogu
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Bailey K Fosdick
- Department of Biostatistics and Informatics, Colorado School of Public Health, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Julia M Dixon
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Smitha Bhaumik
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hendrick J Lategan
- Division of Surgery, Department of Surgical Sciences, Stellenbosch University, Cape Town, South Africa
| | - Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven G Schauer
- Department of Anesthesia, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Elmin Steyn
- Division of Surgery, Department of Surgical Sciences, Stellenbosch University, Cape Town, South Africa
| | - Janette Verster
- Division of Forensic Medicine, Department of Pathology, Stellenbosch University, Cape Town, South Africa
| | - Craig Wylie
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Shaheem de Vries
- Collaborative for Emergency Care in Africa, Cape Town, South Africa
| | - Maria Jamison
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Maria Kohlbrenner
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mohammed Mayet
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Lesley Hodsdon
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Leigh Wagner
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - L' Oreal Snyders
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Karlien Doubell
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Denise Lourens
- Department of Health and Wellness, Western Cape Government, Cape Town, South Africa
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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17
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Ritondale J, Piehl M, Caputo S, Broome J, McLafferty B, Anderson A, Belding C, Tatum D, Duchesne J. Impact of Prehospital Exsanguinating Airway-Breathing-Circulation Resuscitation Sequence on Patients with Severe Hemorrhage. J Am Coll Surg 2024; 238:367-373. [PMID: 38197435 DOI: 10.1097/xcs.0000000000000956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND At the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality. STUDY DESIGN This was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups. RESULTS A total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004). CONCLUSIONS This is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.
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Affiliation(s)
- Joseph Ritondale
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Mark Piehl
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC (Piehl)
- Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, NC (Piehl)
| | - Sydney Caputo
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Jacob Broome
- Department of Surgery, MedStar Georgetown Washington Hospital Center, Washington DC (Broome)
| | - Bryant McLafferty
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Augustus Anderson
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Cameron Belding
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Danielle Tatum
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
| | - Juan Duchesne
- From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne)
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18
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van Wyk P, Wannberg M, Gustafsson A, Yan J, Wikman A, Riddez L, Wahlgren CM. Characteristics of traumatic major haemorrhage in a tertiary trauma center. Scand J Trauma Resusc Emerg Med 2024; 32:24. [PMID: 38528572 DOI: 10.1186/s13049-024-01196-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/15/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Major traumatic haemorrhage is potentially preventable with rapid haemorrhage control and improved resuscitation techniques. Although advances in prehospital trauma management, haemorrhage is still associated with high mortality. The aim of this study was to use a recent pragmatic transfusion-based definition of major bleeding to characterize patients at risk of major bleeding and associated outcomes in this cohort after trauma. METHODS This was a retrospective cohort study including all trauma patients (n = 7020) admitted to a tertiary trauma center from January 2015 to June 2020. The major bleeding cohort (n = 145) was defined as transfusion of 4 units of any blood components (red blood cells, plasma, or platelets) within 2 h of injury. Univariate and multivariable logistic regression analyses were performed to identify risk factors for 24-hour and 30-day mortality post trauma admission. RESULTS In the major bleeding cohort (n = 145; 145/7020, 2.1% of the trauma population), there were 77% men (n = 112) and 23% women (n = 33), median age 39 years [IQR 26-53] and median Injury Severity Score (ISS) was 22 [IQR 13-34]. Blunt trauma dominated over penetrating trauma (58% vs. 42%) where high-energy fall was the most common blunt mechanism and knife injury was the most common penetrating mechanism. The major bleeding cohort was younger (OR 0.99; 95% CI 0.98 to 0.998, P = 0.012), less female gender (OR 0.66; 95% CI 0.45 to 0.98, P = 0.04), and had more penetrating trauma (OR 4.54; 95% CI 3.24 to 6.36, P = 0.001) than the rest of the trauma cohort. A prehospital (OR 2.39; 95% CI 1.34 to 4.28; P = 0.003) and emergency department (ED) (OR 6.91; 95% CI 4.49 to 10.66, P = 0.001) systolic blood pressure < 90 mmHg was associated with the major bleeding cohort as well as ED blood gas base excess < -3 (OR 7.72; 95% CI 5.37 to 11.11; P < 0.001) and INR > 1.2 (OR 3.09; 95% CI 2.16 to 4.43; P = 0.001). Emergency damage control laparotomy was performed more frequently in the major bleeding cohort (21.4% [n = 31] vs. 1.5% [n = 106]; OR 3.90; 95% CI 2.50 to 6.08; P < 0.001). There was no difference in transportation time from alarm to hospital arrival between the major bleeding cohort and the rest of the trauma cohort (47 [IQR 38;59] vs. 49 [IQR 40;62] minutes; P = 0.17). However, the major bleeding cohort had a shorter time from ED to first emergency procedure (71.5 [IQR 10.0;129.0] vs. 109.00 [IQR 54.0; 259.0] minutes, P < 0.001). In the major bleeding cohort, patients with penetrating trauma, compared to blunt trauma, had a shorter alarm to hospital arrival time (44.0 [IQR 35.5;54.0] vs. 50.0 [IQR 41.5;61.0], P = 0.013). The 24-hour mortality in the major bleeding cohort was 6.9% (10/145). All fatalities were due to blunt trauma; 40% (4/10) high energy fall, 20% (2/10) motor vehicle accident, 10% (1/10) motorcycle accident, 10% (1/10) traffic pedestrian, 10% (1/10) traffic other, and 10% (1/10) struck/hit by blunt object. In the logistic regression model, prehospital cardiac arrest (OR 83.4; 95% CI 3.37 to 2063; P = 0.007) and transportation time (OR 0.95, 95% CI 0.91 to 0.99, P = 0.02) were associated with 24-hour mortality. RESULTS Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control. The major bleeding trauma cohort is a small part of the entire trauma population, and is characterized of being younger, male gender, higher ISS, and exposed to more penetrating trauma. Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control.
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Affiliation(s)
- Pieter van Wyk
- Section of Acute and Trauma Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Wannberg
- Department of Molecular Medicine and Surgery, Department of Vascular Surgery, Karolinska Institute, Karolinska University Hospital, SE-171 76, Stockholm, Sweden
| | - Anna Gustafsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Jane Yan
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Agneta Wikman
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Louis Riddez
- Section of Acute and Trauma Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Department of Vascular Surgery, Karolinska Institute, Karolinska University Hospital, SE-171 76, Stockholm, Sweden.
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Riha GM, Johnson A, Arnold S, Englehart MS, Thompson SJ. The Montana Interfacility Blood Network: A Novel Lifesaving "Hand-off" for the Optimal Care of Rural Patients. J Blood Med 2024; 15:141-146. [PMID: 38524734 PMCID: PMC10961070 DOI: 10.2147/jbm.s442134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/01/2024] [Indexed: 03/26/2024] Open
Abstract
Purpose The state of Montana encompasses and defines rural health care as it is known in the United States (US) today. This vast area is punctuated by pockets of health care availability with varying access to blood products for transfusion. Furthermore, timely transport is frequently challenged by weather that may limit air transportation options, resulting in multiple hours in ground transport to definitive care. Patients and Methods The Montana State Trauma Care Committee (MT-STCC) developed the Montana Interfacility Blood Network (MT-IBN) to ensure blood availability in geographically distanced cases where patients may otherwise not survive. The index case that led to the formal development of the MT-IBN is described, followed by a second case illustrating the IBN process. Results This process and development manuscript details the innovative efforts of MT-STCC to develop this fledgling idea unique to rural US health care. We review guidelines that have been developed to define broad aspects of the MT-IBN including the reason to share resources, proper packaging, paperwork necessary for transfer, and how to provide resources directly to the patient. Finally, we describe implementation within the state. Conclusion The MT-IBN was developed by MT-STCC to facilitate the hand-off of lifesaving blood to patients being transported by ground to definitive care in Montana without having to stop at an intermediary facility. This has already led to lives saved in areas that are limited in blood availability due to rurality.
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Affiliation(s)
- Gordon M Riha
- Trauma & General Surgery, Billings Clinic, Billings, MT, USA
| | - Alyssa Johnson
- EMS & Trauma Systems Montana, Chronic Disease Prevention and Health Promotion Bureau, Montana Department of Public Health and Human Services, Helena, MT, USA
| | - Sadie Arnold
- Laboratory Services, Billings Clinic, Billings, MT, USA
| | | | - Simon J Thompson
- Collaborative Science & Innovation, Billings Clinic, Billings, MT, USA
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20
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Facchetti G, Facchetti M, Schmal M, Lee R, Fiorelli S, Marzano TF, Lupi C, Daminelli F, Sbrana G, Massullo D, Marinangeli F. Prehospital Blood Transfusion in Helicopter Emergency Medical Services: An Italian Survey. Air Med J 2024; 43:140-145. [PMID: 38490777 DOI: 10.1016/j.amj.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Hemorrhage remains the most common cause of preventable death after trauma. Prehospital blood product (PHBP) administration may improve outcomes. No data are available about PHBP use in Italian helicopter emergency medical services (HEMS). The primary aim of this survey was to establish the degree of PHBP used throughout Italy. The secondary aims were to evaluate the main indications for their use, the opinions about PHBPs, and users' experience. METHODS The study group performed a telephone/e-mail survey of all 56 Italian HEMS bases. The questions concerned whether PHBPs were used in their HEMS bases, the frequency of transfusions, the PHBP used, and the perceived benefits. RESULTS Four of 56 HEMS bases use PHBPs. Overall, 7% have prehospital access to packed red cells and only 1 to fresh plasma. In addition to blood product administration, 4 of 4 use tranexamic acid, and 3 of 4 also use fibrinogen. Seventy-five percent use PHBPs once a month and 25% once a week. The users' experience was that PHBPs are beneficial and lifesaving. CONCLUSION Only 4 of 56 HEMS in Italy use PHBPs. There is an absolute consensus among providers on the benefit of PHBPs despite the lack of evidence on PHBP use.
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Affiliation(s)
| | - Marilisa Facchetti
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
| | - Mariette Schmal
- Jeugdgezondheidszorg Zuid-Holland West, Zoetermeer, Netherlands
| | - Ronan Lee
- European Patent Office, Team Surgery, Rijswijk, Netherlands
| | - Silvia Fiorelli
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | | | - Cristian Lupi
- HEMS Bologna, Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Azienda Unità Sanitaria Locale Bologna, Bologna, Italy
| | - Francesco Daminelli
- HEMS Bergamo, Papa Giovanni XXIII Hospital, Agenzia Regionale Emergenza Urgenza Lombardia, Bergamo, Italy
| | - Giovanni Sbrana
- HEMS Grosseto, Emergency Department, Azienda Sanitaria Locale Toscana Sud Est, Grosseto, Italy
| | - Domenico Massullo
- Anesthesia and Intensive Care Medicine, Department of Clinical and Surgical Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Franco Marinangeli
- Department Anesthesiology and Critical Care, University of L'Aquila, L'Aquila, Italy
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21
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Gauss T, Bouzat P. Trauma coagulopathy: Insights from the PROCOAG and CRYOSTAT-2 trials. Coagulation factors are not antibiotics. Anaesth Crit Care Pain Med 2024; 43:101360. [PMID: 38395358 DOI: 10.1016/j.accpm.2024.101360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Tobias Gauss
- Service Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Inserm, U1216, Grenoble Institute Neurosciences, Grenoble, France.
| | - Pierre Bouzat
- Service Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France; Université Grenoble Alpes, Inserm, U1216, Grenoble Institute Neurosciences, Grenoble, France
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22
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Abuelazm M, Rezq H, Mahmoud A, Tanashat M, Salah A, Saleh O, Morsi S, Abdelazeem B. The efficacy and safety of pre-hospital plasma in patients at risk for hemorrhagic shock: an updated systematic review and meta-analysis of randomized controlled trials. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02461-7. [PMID: 38367091 DOI: 10.1007/s00068-024-02461-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/22/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND AND OBJECTIVE Plasma is a critical element in hemostatic resuscitation post-injury, and its prompt administration within the prehospital setting may reduce the complications resulting from hemorrhage and shock. Our objective is to assess the efficacy and safety of prehospital plasma infusion in patients susceptible to hemorrhagic shock. METHODS We conducted our study by aggregating randomized controlled trials (RCTs) sourced from PubMed, EMBASE, Scopus, Web of Science, and Cochrane CENTRAL up to January 29, 2023. Quality assessment was implemented using the Cochrane RoB 2 tool. Our study protocol is registered in PROSPERO under ID: CRD42023397325. RESULTS Three RCTs with 760 individuals were included. There was no difference between plasma infusion and standard care groups in 24-h mortality (P = 0.11), 30-day mortality (P = 0.12), and multiple organ failure incidences (P = 0.20). Plasma infusion was significantly better in the total 24-h volume of PRBC units (P = 0.03) and INR on arrival (P = 0.009). For all other secondary outcomes evaluated (total 24-h volume of packed FFP units, total 24-h volume of platelets units, massive transfusion, vasopressor need during the first 24 h, any adverse event, acute lung injury, transfusion reaction, and sepsis), no significant differences were observed between the two groups. CONCLUSION Plasma infusion in trauma patients at risk of hemorrhagic shock does not significantly affect mortality or the incidence of multiple organ failure. However, it may lead to reduced packed red blood cell transfusions and increased INR at hospital arrival.
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Affiliation(s)
| | - Hazem Rezq
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
| | | | | | | | - Othman Saleh
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Samah Morsi
- Department of Radiation Oncology, UT Texas MD Anderson, Houston, TX, USA
| | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
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23
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Wigginton O, Johnson S, Jervis B, Joshi A, Steere M, Ferguson I. Prehospital Blood Transfusion: A Cross-Sectional Study of Prehospital and Retrieval Medicine Services across Australia & Aotearoa-New Zealand. PREHOSP EMERG CARE 2024:1-5. [PMID: 38241180 DOI: 10.1080/10903127.2024.2306249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND The frequency and type of prehospital blood product delivery across Australia and Aotearoa-New Zealand is unknown. This study aims to describe transfusion practice across different services in the two nations, as well as identifying potential barriers to the carriage of blood products. METHODOLOGY Prehospital and retrieval medicine services operating teams of doctors, specialist paramedics, and/or flight nurses out of specialty bases across Australia and Aotearoa-New Zealand were sent a standardized questionnaire regarding their base characteristics and their current blood transfusion practice. Bases that only performed inter-hospital transfers or search & rescue operations were excluded. Bases were queried on personnel, equipment, transport times, type and volume of blood products carried, frequency of use, and barriers to implementation for those without prehospital blood transfusion programs. RESULTS 64 bases were identified and contacted, of which 5 were excluded and 45 of the remaining 59 (76.3%) responded. 62% (28/45) of respondents routinely carry prehospital blood products. 78.6% (22/28) carried packed red blood cells (PRBC) only, 14.3% (4/28) carried both PRBC and plasma, and 1 service (3.6%) carried whole blood. The mean number of units of blood product carried was 3.3 (SD 0.82). 2 bases (7.1%) carried fibrinogen concentrate. All services carried tranexamic acid and calcium. 734 patients received a blood transfusion in 2021, with trauma being the most common indication (552, 75.2%). Base characteristics varied significantly in staffing, vehicle platform and transfer times. The median transfer time from scene to hospital was 65 min (IQR of 40-92). Services without access to prehospital blood products identified multiple barriers to implementation, including training and supply chain. CONCLUSION Approximately two-thirds of prehospital services operating advanced teams across Australia and Aotearoa-New Zealand carried blood products and there was wide variation both in the type and number of blood products carried by each base. Multiple barriers to the carriage of blood by all bases were reported, which have implications for service equity. Transfer times are generally long in Australia and Aotearoa-New Zealand, which may impact the generalizability of overseas research performed in prehospital systems with significantly shorter transfer times to services operating in Australia and Aotearoa-New Zealand.
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Affiliation(s)
- Oscar Wigginton
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Sue Johnson
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- Auckland Rescue Helicopter Trust (ARHT), Auckland, Aotearoa-New Zealand
| | - Bethan Jervis
- CareFlight Australia, Northmead, New South Wales, Australia
| | - Anil Joshi
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- Auckland Rescue Helicopter Trust (ARHT), Auckland, Aotearoa-New Zealand
| | - Mardi Steere
- Royal Flying Doctor Service, RFDS Central Operations, Adelaide, South Australia, Australia
| | - Ian Ferguson
- Aeromedical Retrieval Service, New South Wales Ambulance, Bankstown, New South Wales, Australia
- South West Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Liverpool Hospital, Liverpool, New South Wales, Australia
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Pusateri AE, Morgan CG, Neidert LE, Tiller MM, Glaser JJ, Weiskopf RB, Ebrahim I, Stassen W, Rambharose S, Mahoney SH, Wallis LA, Hollis EM, Delong GT, Cardin S. Safety of Bioplasma FDP and Hemopure in rhesus macaques after 30% hemorrhage. Trauma Surg Acute Care Open 2024; 9:e001147. [PMID: 38196929 PMCID: PMC10773430 DOI: 10.1136/tsaco-2023-001147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/03/2023] [Indexed: 01/11/2024] Open
Abstract
Objectives Prehospital transfusion can be life-saving when transport is delayed but conventional plasma, red cells, and whole blood are often unavailable out of hospital. Shelf-stable products are needed as a temporary bridge to in-hospital transfusion. Bioplasma FDP (freeze-dried plasma) and Hemopure (hemoglobin-based oxygen carrier; HBOC) are products with potential for prehospital use. In vivo use of these products together has not been reported. This study assessed the safety of intravenous administration of HBOC+FDP, relative to normal saline (NS), in rhesus macaques (RM). Methods After 30% blood volume removal and 30 minutes in shock, animals were resuscitated with either NS or two units (RM size adjusted) each of HBOC+FDP during 60 minutes. Sequential blood samples were collected. After neurological assessment, animals were killed at 24 hours and tissues collected for histopathology. Results Due to a shortage of RM during the COVID-19 pandemic, the study was stopped after nine animals (HBOC+FDP, seven; NS, two). All animals displayed physiologic and tissue changes consistent with hemorrhagic shock and recovered normally. There was no pattern of cardiovascular, blood gas, metabolic, coagulation, histologic, or neurological changes suggestive of risk associated with HBOC+FDP. Conclusion There was no evidence of harm associated with the combined use of Hemopure and Bioplasma FDP. No differences were noted between groups in safety-related cardiovascular, pulmonary, renal or other organ or metabolic parameters. Hemostasis and thrombosis-related parameters were consistent with expected responses to hemorrhagic shock and did not differ between groups. All animals survived normally with intact neurological function. Level of evidence Not applicable.
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Affiliation(s)
| | - Clifford G Morgan
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Leslie E Neidert
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Michael M Tiller
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas, USA
| | - Jacob J Glaser
- Providence Regional Medical Center, Everett, Washington, USA
| | - Richard B Weiskopf
- Department of Anesthesia and Perioperative Medcine, University of California San Francisco, San Francisco, California, USA
| | - Ismaeel Ebrahim
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Willem Stassen
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Sanjeev Rambharose
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Scott H Mahoney
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Lee A Wallis
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Ewell M Hollis
- Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Gerald T Delong
- Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
| | - Sylvain Cardin
- Naval Medical Research Unit San Antonio, Fort Sam Houston, Texas, USA
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25
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Silver DS, Sperry JL, Beiriger J, Lu L, Guyette FX, Wisniewski S, Moore EE, Schreiber M, Joseph B, Wilson CT, Cotton B, Ostermayer D, Fox EE, Harbrecht BG, Patel M, Brown JB. Association Between Emergency Medical Service Agency Volume and Mortality in Trauma Patients. Ann Surg 2024; 279:160-166. [PMID: 37638408 PMCID: PMC10840871 DOI: 10.1097/sla.0000000000006087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the association of annual trauma patient volume on outcomes for emergency medical services (EMS) agencies. BACKGROUND Regionalization of trauma care saves lives. The underlying concept driving this is a volume-outcome relationship. EMS are the entry point to the trauma system, yet it is unknown if a volume-outcome relationship exists for EMS. METHODS A retrospective analysis of prospective cohort including 8 trauma centers and 20 EMS air medical and metropolitan ground transport agencies. Patients 18 to 90 years old with injury severity scores ≥9 transported from the scene were included. Patient and agency-level risk-adjusted regression determined the association between EMS agency trauma patient volume and early mortality. RESULTS A total of 33,511 were included with a median EMS agency volume of 374 patients annually (interquartile range: 90-580). Each 50-patient increase in EMS agency volume was associated with 5% decreased odds of 6-hour mortality (adjusted odds ratio=0.95; 95% CI: 0.92-0.99, P =0.03) and 3% decreased odds of 24-hour mortality (adjusted odds ratio=0.97; 95% CI: 0.95-0.99, P =0.04). Prespecified subgroup analysis showed EMS agency volume was associated with reduced odds of mortality for patients with prehospital shock, requiring prehospital airway placement, undergoing air medical transport, and those with traumatic brain injury. Agency-level analysis demonstrated that high-volume (>374 patients/year) EMS agencies had a significantly lower risk-standardized 6-hour mortality rate than low-volume (<374 patients/year) EMS agencies (1.9% vs 4.8%, P <0.01). CONCLUSIONS A higher volume of trauma patients transported at the EMS agency level is associated with improved early mortality. Further investigation of this volume-outcome relationship is necessary to leverage quality improvement, benchmarking, and educational initiatives.
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Affiliation(s)
- David S Silver
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jamison Beiriger
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Liling Lu
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stephen Wisniewski
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Ernest E Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO
| | - Martin Schreiber
- Division of Trauma, Critical Care, & Acute Care Surgery, Oregon Health & Science University, Portland, OR
| | - Bellal Joseph
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of Arizona, Tucson, AZ
| | - Chad T Wilson
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Bryan Cotton
- Department of Surgery, Division of Acute Care Surgery and Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | - Daniel Ostermayer
- Department of Emergency Medicine, University of Texas Health Science Center, McGovern Medical School, Houston, TX
| | - Erin E Fox
- Department of Surgery, Division of Acute Care Surgery and Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, TX
| | | | - Mayur Patel
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Shackelford SA, Del Junco DJ, Mazuchowski EL, Kotwal RS, Remley MA, Keenan S, Gurney JM. The Golden Hour of Casualty Care: Rapid Handoff to Surgical Team is Associated With Improved Survival in War-injured US Service Members. Ann Surg 2024; 279:1-10. [PMID: 36728667 DOI: 10.1097/sla.0000000000005787] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine time from injury to initiation of surgical care and association with survival in US military casualties. BACKGROUND Although the advantage of trauma care within the "golden hour" after an injury is generally accepted, evidence is scarce. METHODS This retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007 to December 2015, alive at initial request for evacuation with maximum abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions: (1) handoff alive to the surgical team, and (2) initiation of first surgery were analyzed as time-dependent covariates (elapsed time from injury) using sequential Cox proportional hazards regression to assess how intervention timing might affect mortality. Covariates included age, injury year, and injury severity. RESULTS Among 5269 patients (median age, 24 years; 97% males; and 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, and 90% within 4 hours. Only handoffs within 1 hour of injury and the resultant timely initiation of emergency surgery (adjusted also for prior advanced resuscitative interventions) were significantly associated with reduced 24-hour mortality compared with more delayed surgical care (adjusted hazard ratios: 0.34; 95% CI: 0.14-0.82; P = 0.02; and 0.40; 95% CI: 0.20-0.81; P = 0.01, respectively). In-hospital waits for surgery (mean: 1.1 hours; 95% CI; 1.0-1.2) scarcely contributed ( P = 0.67). CONCLUSIONS Rapid handoff to the surgical team within 1 hour of injury may reduce mortality by 66% in US military casualties. In the subgroup of casualties with indications for emergency surgery, rapid handoff with timely surgical intervention may reduce mortality by 60%. To inform future research and trauma system planning, findings are pivotal.
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Affiliation(s)
| | | | - Edward L Mazuchowski
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
- Armed Forces Medical Examiner System, Defense Health Agency, Dover AFB, DE
| | - Russ S Kotwal
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
| | - Michael A Remley
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
| | - Sean Keenan
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
| | - Jennifer M Gurney
- Joint Trauma System, Defense Health Agency, Fort Sam Houston, TX
- US Army Institute of Surgical Research, Fort Sam Houston, TX
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Blais-Normandin I, Rymer T, Feenstra S, Burry A, Colavecchia C, Duncan J, Farrell M, Greene A, Gupta A, Huynh Q, Lawrence R, Lehto P, Lett R, Lin Y, Lyon B, McCarthy J, Nahirniak S, Nolan B, Peddle M, Prokopchuk-Gauk O, Sham L, Trojanowski J, Shih AW. Current state of technical transfusion medicine practice for out-of-hospital blood transfusion in Canada. Vox Sang 2023; 118:1086-1094. [PMID: 37794849 DOI: 10.1111/vox.13542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Canadian out-of-hospital blood transfusion programmes (OHBTPs) are emerging, to improve outcomes of trauma patients by providing pre-hospital transfusion from the scene of injury, given prolonged transport times. Literature is lacking to guide its implementation. Thus, we sought to gather technical transfusion medicine (TM)-specific practices across Canadian OHBTPs. MATERIALS AND METHODS A survey was sent to TM representatives of Canadian OHBTPs from November 2021 to March 2022. Data regarding transport, packaging, blood components and inventory management were included and reported descriptively. Only practices involving Blood on Board programme components for emergency use were included. RESULTS OHBTPs focus on helicopter emergency medical service programmes, with some supplying fixed-wing aircraft and ground ambulances. All provide 1-3 coolers with 2 units of O RhD/Kell-negative red blood cells (RBCs) per cooler, with British Columbia trialling coolers with 2 units of pre-thawed group A plasma. Inventory exchanges are scheduled and blood components are returned to TM inventory using visual inspection and internal temperature data logger readings. Coolers are validated to storage durations ranging from 72 to 124 h. All programmes audit to manage wastage, though there is no consensus on appropriate benchmarks. All programmes have a process for documenting units issued, reconciliation after transfusion and for transfusion reaction reporting; however, training programmes vary. Common considerations included storage during extreme temperature environments, O-negative RBC stewardship, recipient notification, traceability, clinical practice guidelines co-reviewed by TM and a common audit framework. CONCLUSION OHBTPs have many similarities throughout Canada, where harmonization may assist in further developing standards, leveraging best practice and national coordination.
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Affiliation(s)
- Isabelle Blais-Normandin
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tihiro Rymer
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Shelley Feenstra
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Anne Burry
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | | | - Jennifer Duncan
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Island Health Authority, Courtenay, British Columbia, Canada
| | - Michael Farrell
- Provincial Blood Coordinating Team, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Adam Greene
- British Columbia Emergency Health Services, Parksville, British Columbia, Canada
| | - Akash Gupta
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Queenie Huynh
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robin Lawrence
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Paula Lehto
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Ryan Lett
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
- Department of Anesthesiology, Regina, Saskatchewan, Canada
| | - Yulia Lin
- Vancouver Island Health Authority, Courtenay, British Columbia, Canada
- Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Bruce Lyon
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Joanna McCarthy
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
| | - Susan Nahirniak
- Alberta Precision Labs, Transfusion and Transplantation Medicine, Edmonton, Alberta, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Brodie Nolan
- Provincial Blood Coordinating Team, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Emergency Medicine, Unity Health Toronto, Toronto, Ontario, Canada
| | - Michael Peddle
- Ornge, Mississauga, Ontario, Canada
- Division of Emergency Medicine, Western University, London, Ontario, Canada
| | - Oksana Prokopchuk-Gauk
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
- Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lawrence Sham
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Jan Trojanowski
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
- Department of Emergency Medicine, Vancouver, British Columbia, Canada
- British Columbia Emergency Health Services, Vancouver, British Columbia, Canada
| | - Andrew W Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
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Smith JE, Barnard EBG, Brown-O'Sullivan C, Cardigan R, Davies J, Hawton A, Laing E, Lucas J, Lyon R, Perkins GD, Smith L, Stanworth SJ, Weaver A, Woolley T, Green L. The SWiFT trial (Study of Whole Blood in Frontline Trauma)-the clinical and cost effectiveness of pre-hospital whole blood versus standard care in patients with life-threatening traumatic haemorrhage: study protocol for a multi-centre randomised controlled trial. Trials 2023; 24:725. [PMID: 37964393 PMCID: PMC10644622 DOI: 10.1186/s13063-023-07711-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Early blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h. METHODS This is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants-after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848). DISCUSSION The SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting. TRIAL REGISTRATION ISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021.
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Affiliation(s)
- Jason E Smith
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK.
- University Hospitals Plymouth NHS Trust, Plymouth, UK.
| | - Ed B G Barnard
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Rebecca Cardigan
- NHS Blood & Transplant, Bristol, UK
- Department of Haematology, University of Cambridge, Cambridge, UK
| | | | - Annie Hawton
- Health Economics Group, University of Exeter, Exeter, UK
| | - Emma Laing
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Joanne Lucas
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Richard Lyon
- Air Ambulance Kent Surrey Sussex, Rochester, UK
- Department of Health Sciences, University of Surrey, Guildford, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Laura Smith
- NHS Blood and Transplant Clinical Trials Unit, Cambridge, UK
| | - Simon J Stanworth
- NHS Blood & Transplant, Bristol, UK
- Oxford University Hospitals, Oxford, UK
- University of Oxford, Oxford, UK
| | - Anne Weaver
- London's Air Ambulance and Royal London Hospital, London, UK
| | - Tom Woolley
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - Laura Green
- NHS Blood & Transplant, Bristol, UK
- Barts Health NHS Trust, London, UK
- Queen Mary University of London, London, UK
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Hsu CH, Chen CH, Chou PH. Potential Limitations for Assessing the Association of Whole Blood With Survival in Patients With Severe Hemorrhage. JAMA Surg 2023; 158:1226-1227. [PMID: 37379031 DOI: 10.1001/jamasurg.2023.1840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Affiliation(s)
- Chia-Hao Hsu
- Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chung-Hwan Chen
- Orthopaedic Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Hsi Chou
- Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
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Maegele M, Lier H, Hossfeld B. Pre-Hospital Blood Products for the Care of Bleeding Trauma Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:670-676. [PMID: 37551452 PMCID: PMC10644958 DOI: 10.3238/arztebl.m2023.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Controversy surrounds the administration of blood products to severely traumatized patients before they arrive in the hospital in order to compensate for early blood loss and/or to correct coagulation disturbances that arise shortly after the traumatic event. A number of terrestrial and air rescue services have begun to provide this kind of treatment. METHODS This review is based on articles using the PICO framework, published from January 2001 to January 2021, that were retrieved by a selective search, with structured searching strategies and searching bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos. A demand analysis was carried out on the basis of data from the trauma registry of the German Society of Trauma Surgery (TR-DGU) and practical experience from program development and implementation was provided by the Bundeswehr Hospital Ulm. RESULTS The currently available evidence on the pre-hospital administration of blood products in the early treatment of severely injured patients is based largely on retrospective, single-center case series. Two randomized controlled trials (RCTs) concerning the early use of fresh frozen plasma concentrates have yielded partly conflicting results. Three further RCTs on the use of lyophilized plasma (lyplas), lyplas plus erythrocyte concentrate, or whole blood likewise revealed non-uniform effects on short-term and intermediate-term mortality. Our demand analysis based on data from the TR-DGU showed that 300 to 1800 patients per year in Germany could benefit from the pre-hospital administration of blood products. This might be indicated in patients who have systolic hypotension (<100 mmHg) in combination with a suspected or confirmed hemorrhage, as well as pathological shock parameters in the point-of-care diagnostic testing performed on the scene (serum base excess ≤ -2.5 mmol/L and/or serum lactate concentration >4 mmol/L). CONCLUSION The studies that have been published to date yield no clear evidence either for or against the early pre-hospital administration of blood products. Any treatment of this kind should be accompanied by scientific evaluation.
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Affiliation(s)
- Marc Maegele
- *Joint first authors
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Campus Cologne-Merheim, Cologne
| | - Heiko Lier
- *Joint first authors
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm
- Rescue transport helicopter (RTH) „Christoph 22“ Ulm, ADAC-Air Rescue, Ulm
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Stassen W, Wylie C, Craig W, Ebrahim I, Mahoney SH, Pusateri AE, Rambharose S, van Koningsbruggen C, Weiskopf RB, Wallis LA. The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study. PREHOSP EMERG CARE 2023; 28:864-870. [PMID: 37713658 DOI: 10.1080/10903127.2023.2259998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. METHODS This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. RESULTS Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. CONCLUSION In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.
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Affiliation(s)
- Willem Stassen
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Craig Wylie
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Wesley Craig
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Ismaeel Ebrahim
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Scott H Mahoney
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
| | - Anthony E Pusateri
- Naval Medical Research Unit-San Antonio, Fort Sam Houston, San Antonio, Texas, USA
| | - Sanjeev Rambharose
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
| | | | | | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
- Division of Emergency Medicine, Stellenbosch University, Stellenbosch, South Africa
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Mitra B, Meadley B, Bernard S, Maegele M, Gruen RL, Bradley O, Wood EM, McQuilten ZK, Fitzgerald M, St. Clair T, Webb A, Anderson D, Reade MC. Pre-hospital freeze-dried plasma for critical bleeding after trauma: A pilot randomized controlled trial. Acad Emerg Med 2023; 30:1013-1019. [PMID: 37103482 PMCID: PMC10946458 DOI: 10.1111/acem.14745] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Transfusion of a high ratio of plasma to packed red blood cells (PRBCs), to treat or prevent acute traumatic coagulopathy, has been associated with survival after major trauma. However, the effect of prehospital plasma on patient outcomes has been inconsistent. The aim of this pilot trial was to assess the feasibility of transfusing freeze-dried plasma with red blood cells (RBCs) using a randomized controlled design in an Australian aeromedical prehospital setting. METHODS Patients attended by helicopter emergency medical service (HEMS) paramedics with suspected critical bleeding after trauma managed with prehospital RBCs were randomized to receive 2 units of freeze-dried plasma (Lyoplas N-w) or standard care (no plasma). The primary outcome was the proportion of eligible patients enrolled and provided the intervention. Secondary outcomes included preliminary data on effectiveness, including mortality censored at 24 h and at hospital discharge, and adverse events. RESULTS During the study period of June 1 to October 31, 2022, there were 25 eligible patients, of whom 20 (80%) were enrolled in the trial and 19 (76%) received the allocated intervention. Median time from randomization to hospital arrival was 92.5 min (IQR 68-101.5 min). Mortality may have been lower in the freeze-dried plasma group at 24 h (RR 0.24, 95% CI 0.03-1.73) and at hospital discharge (RR 0.73, 95% CI 0.24-2.27). No serious adverse events related to the trial interventions were reported. CONCLUSIONS This first reported experience of freeze-dried plasma use in Australia suggests prehospital administration is feasible. Given longer prehospital times typically associated with HEMS attendance, there is potential clinical benefit from this intervention and rationale for a definitive trial.
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Affiliation(s)
- Biswadev Mitra
- Alfred Health Emergency ServicesMelbourneVictoriaAustralia
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Ben Meadley
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
| | - Stephen Bernard
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
- Department of Intensive CareThe Alfred HospitalMelbourneVictoriaAustralia
| | - Marc Maegele
- Department of Traumatology and Orthopaedic SurgeryCologne‐Merheim Medical CentreCologneGermany
- Institute for Research in Operative Medicine, Experimental/Clinical Research UnitUniversity Witten‐HerdeckeCologneGermany
| | - Russell L. Gruen
- College of Health and MedicineAustralian National UniversityCanberraAustralian Capital TerritoryAustralia
| | | | - Erica M. Wood
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of HaematologyMonash HealthMelbourneVictoriaAustralia
| | - Zoe K. McQuilten
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of HaematologyMonash HealthMelbourneVictoriaAustralia
| | - Mark Fitzgerald
- Trauma ServiceThe Alfred HospitalMelbourneVictoriaAustralia
- Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
- National Trauma Research InstituteMelbourneVictoriaAustralia
| | - Toby St. Clair
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
| | - Andrew Webb
- Department of HaematologyThe Alfred HospitalPrahran, MelbourneVictoriaAustralia
| | - David Anderson
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
- Department of Intensive CareThe Alfred HospitalMelbourneVictoriaAustralia
| | - Michael C. Reade
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Faculty of MedicineRoyal Brisbane and Women's Hospital, The University of QueenslandHerstonQueenslandAustralia
- Joint Health Command, Australian Defence ForceCanberraAustralian Capital TerritoryAustralia
- Department of Intensive Care MedicineRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
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Zhou Y, Wang B, Wang J, Zhang M. A case report of severe unstable pelvic fracture with extensive perineal destruction and Morel-Lavallee lesion, with literature review. Int J Surg Case Rep 2023; 111:108905. [PMID: 37820481 PMCID: PMC10570939 DOI: 10.1016/j.ijscr.2023.108905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/11/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Unstable pelvic fractures in children are mainly caused by high-impact injuries, which are often combined with multiple injuries. A rare type of degloving injury named Morel-Lavallee lesion (MLL) is easily overlooked in obese children. CASE PRESENTATION A case of unstable pelvic fracture combined with extensive perineal injury and MLL in an obese child was discussed. The general conditions, diagnosis, and treatment were summarized. CLINICAL DISCUSSION Unstable pelvic fractures are associated with extremely high disability and mortality rates and are often associated with hemorrhagic shock, urethral injury, or lower-extremity dysfunction. Clinicians need to be more alert to the possibility of MLL in obese children. CONCLUSION Multidisciplinary diagnosis and treatment with individualized surgical procedures are key to a good prognosis.
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Affiliation(s)
- Ying Zhou
- Department of Surgical Intensive Care Unit, Children's Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu, China
| | - Bo Wang
- Department of Surgical Intensive Care Unit, Children's Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu, China
| | - Jing Wang
- Department of Surgical Intensive Care Unit, Children's Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu, China
| | - Ming Zhang
- Department of Surgical Intensive Care Unit, Children's Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu, China.
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Breslin JW. Edema and lymphatic clearance: molecular mechanisms and ongoing challenges. Clin Sci (Lond) 2023; 137:1451-1476. [PMID: 37732545 PMCID: PMC11025659 DOI: 10.1042/cs20220314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/18/2023] [Accepted: 08/31/2023] [Indexed: 09/22/2023]
Abstract
Resolution of edema remains a significant clinical challenge. Conditions such as traumatic shock, sepsis, or diabetes often involve microvascular hyperpermeability, which leads to tissue and organ dysfunction. Lymphatic insufficiency due to genetic causes, surgical removal of lymph nodes, or infections, leads to varying degrees of tissue swelling that impair mobility and immune defenses. Treatment options are limited to management of edema as there are no specific therapeutics that have demonstrated significant success for ameliorating microvascular leakage or impaired lymphatic function. This review examines current knowledge about the physiological, cellular, and molecular mechanisms that control microvascular permeability and lymphatic clearance, the respective processes for interstitial fluid formation and removal. Clinical conditions featuring edema, along with potential future directions are discussed.
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Affiliation(s)
- Jerome W Breslin
- Department of Molecular Pharmacology and Physiology, Morsani College of Medicine, University of South Florida, FL, U.S.A
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Cohen MJ, Erickson CB, Lacroix IS, Debot M, Dzieciatkowska M, Schaid TR, Hallas MW, Thielen ON, Cralley AL, Banerjee A, Moore EE, Silliman CC, D'Alessandro A, Hansen KC. Trans-Omics analysis of post injury thrombo-inflammation identifies endotypes and trajectories in trauma patients. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.08.16.553446. [PMID: 37645811 PMCID: PMC10462097 DOI: 10.1101/2023.08.16.553446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Understanding and managing the complexity of trauma-induced thrombo-inflammation necessitates an innovative, data-driven approach. This study leveraged a trans-omics analysis of longitudinal samples from trauma patients to illuminate molecular endotypes and trajectories that underpin patient outcomes, transcending traditional demographic and physiological characterizations. We hypothesize that trans-omics profiling reveals underlying clinical differences in severely injured patients that may present with similar clinical characteristics but ultimately have very different responses to treatment and clinical outcomes. Here we used proteomics and metabolomics to profile 759 of longitudinal plasma samples from 118 patients at 11 time points and 97 control subjects. Results were used to define distinct patient states through data reduction techniques. The patient groups were stratified based on their shock severity and injury severity score, revealing a spectrum of responses to trauma and treatment that are fundamentally tied to their unique underlying biology. Ensemble models were then employed, demonstrating the predictive power of these molecular signatures with area under the receiver operating curves of 80 to 94% for key outcomes such as INR, ICU-free days, ventilator-free days, acute lung injury, massive transfusion, and death. The molecularly defined endotypes and trajectories provide an unprecedented lens to understand and potentially guide trauma patient management, opening a path towards precision medicine. This strategy presents a transformative framework that aligns with our understanding that trauma patients, despite similar clinical presentations, might harbor vastly different biological responses and outcomes.
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Manning JE, Morrison JJ, Pepe PE. Prehospital Resuscitation: What Should It Be? Adv Surg 2023; 57:233-256. [PMID: 37536856 DOI: 10.1016/j.yasu.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Prehospital resuscitation is a dynamic field now being energized by new technologies and a shift in thinking regarding intravascular resuscitation. Growing evidence discourages use of intravenous (IV) crystalloid and colloid solutions in trauma, whereas blood products, particularly whole blood, are becoming preferred. Although randomized clinical trials validating definitive resuscitative protocols are still lacking, most preclinical and clinical indicators support this approach. In addition, emerging technologies such as external and endovascular hemorrhage control devices and extracorporeal perfusion are now being used routinely, even in the prehospital setting in many countries, generating new lines of emerging investigations for trauma specialists.
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Affiliation(s)
- James E Manning
- Department of Emergency Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, CB# 7594, Chapel Hill, NC 27599-7594, USA.
| | - Jonathan J Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Paul E Pepe
- University of Miami, Miller School of Medicine, Miami, FL, USA; Dallas County Public Safety, Emergency Medical Services, Dallas, TX, USA; Global Emergency Medical Services, Suite 307 Point of Americas One, 2100 South Ocean Lane, Fort Lauderdale, FL 33316-3823, USA
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Cornelius B, Thompson D, Kilgore P, Cvek U, Trutschl M, Samra N, Cornelius A. Air Medical Blood Transfusion as a Trigger of Massive Transfusion Protocol. Air Med J 2023; 42:353-357. [PMID: 37716807 PMCID: PMC10540275 DOI: 10.1016/j.amj.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/19/2023] [Accepted: 05/14/2023] [Indexed: 09/18/2023]
Abstract
Air medical services can improve access to blood products at the point of injury. Studies have shown that early activation of mass transfusion protocols (MTPs) can improve the survival of trauma patients by up to 25%. There are several scoring systems to guide early activation, but the use of a single criterion has been elusive. Our study sought to determine if air medical administration of blood products was a risk factor for massive transfusion activation and utilization of prehospital vital signs for calculation of the shock index. In our retrospective study, we evaluated adult trauma patients transfused by helicopter emergency medical services (HEMS) and as a control all patients in our institution receiving the MTP. Our study found HEMS blood transfusion was not a reliable trigger for MTP, although the sample size may have limited our findings. We found that HEMS care resulted in an overall reduction in the volume of transfusion and an improvement in hemodynamic parameters upon trauma center arrival. HEMS transfusion and a higher rate of tranexamic acid administration may have contributed to these findings. Of note, the assessment of blood consumption score and shock index were nonspecific in the study populations.
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Affiliation(s)
- Brian Cornelius
- Graduate Program in Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX; Department of Anesthesia, John Peter Smith Hospital, Fort Worth, TX; Department of Anesthesia, Ochsner LSU Health, Shreveport, LA.
| | - Dennis Thompson
- Department of Emergency Medicine, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Phillip Kilgore
- Laboratory for Advanced Biomedical Informatics, Department of Computer Science, Louisiana State University Shreveport, LA
| | - Urska Cvek
- Laboratory for Advanced Biomedical Informatics, Department of Computer Science, Louisiana State University Shreveport, LA
| | - Marjan Trutschl
- Laboratory for Advanced Biomedical Informatics, Department of Computer Science, Louisiana State University Shreveport, LA
| | - Navdeep Samra
- Department of Trauma and Surgical Critical Care, Louisiana State University Health Sciences Center, Shreveport, LA
| | - Angela Cornelius
- Department of Emergency Medicine, Louisiana State University Health Sciences Center, Shreveport, LA; Department of Emergency Medicine, John Peter Smith Hospital, Fort Worth, TX
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Jakob DA, Müller M, Jud S, Albrecht R, Hautz W, Pietsch U. The forgotten cohort-lessons learned from prehospital trauma death: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:37. [PMID: 37550763 PMCID: PMC10405424 DOI: 10.1186/s13049-023-01107-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/31/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Trauma related deaths remain a relevant public health problem, in particular in the younger male population. A significant number of these deaths occur prehospitally without transfer to a hospital. These patients, sometimes termed "the forgotten cohort", are usually not included in clinical registries, resulting in a lack of information about prehospitally trauma deaths. The aim of the present study was to compare patients who died prehospital with those who sustained life-threatening injuries in order to analyze and potentially improve prehospital strategies. METHODS This cohort study included all primary operations carried out by Switzerland's largest helicopter emergency medical service (HEMS) between January 1, 2011, and December 31, 2021. We included all adult trauma patients with life-threatening or fatal conditions. The outcome of this study is the vital status of the patient at the end of mission, i.e. fatal or life-threatening. Injury, rescue characteristics, and interventions of the forgotten trauma cohort, defined as patients with a fatal injury (NACA score of VII), were compared with life-threatening injuries (NACA score V and VI). RESULTS Of 110,331 HEMS missions, 5534 primary operations were finally analyzed, including 5191 (93.8%) life-threatening and 343 (6.2%) fatal injuries. More than two-thirds of patients (n = 3772, 68.2%) had a traumatic brain injury without a significant difference between the two groups (p > 0.05). Thoracic trauma (44.6% vs. 28.7%, p < 0.001) and abdominal trauma (22.2% vs. 16.1%, p = 0.004) were more frequent in fatal missions whereas pelvic trauma was similar between the two groups (13.4% vs. 12.9%, p = 0.788). Pneumothorax decompression rate (17.2% vs. 3.7%, p < 0.001) was higher in the forgotten cohort group and measures for bleeding control (15.2% vs. 42.7%, p < 0.001) and pelvic belt application (2.9% vs. 13.1% p < 0.001) were more common in the life-threating injury group. CONCLUSION Chest decompression rates and measures for early hemorrhage control are areas for potential improvement in prehospital care.
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Affiliation(s)
- Dominik A Jakob
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Sebastian Jud
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Roland Albrecht
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland
| | - Wolf Hautz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Urs Pietsch
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
- Department of Anesthesiology and Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Swiss Air-Ambulance, Rega (Rettungsflugwacht/Guarde Aérienne), Zurich, Switzerland
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Ye H, Du Y, Jin Y, Liu F, He S, Guo Y. Articles on hemorrhagic shock published between 2000 and 2021: A CiteSpace-Based bibliometric analysis. Heliyon 2023; 9:e18840. [PMID: 37636355 PMCID: PMC10450864 DOI: 10.1016/j.heliyon.2023.e18840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023] Open
Abstract
Objective To conduct a bibliometric analysis of literature on hemorrhagic shock published between 2000 and 2021 with the help of Citespace to explore the current status, hotspots and research trends in this regard, with the results presented in a visualized manner. Methods The data over the past 22 years were retrieved from the Web of Science (WOS) Core Collection database and downloaded as the "Full Record and Cited References". Cooperative analysis, cluster analysis, co-citation analysis, and burst analysis were performed based on the data on countries/regions, institutions, journals, authors, and keywords through Citespace. Results A total of 2027 articles were retrieved. The number of annual publications fluctuated but was generally on an upward trend. The United States stands out as the most productive country (989 articles), the University of Pittsburgh the most productive publishing institution (109 articles), SHOCK the most cited journal (1486 articles), TAO LI the most productive author (40 articles), DEITCH EA the most cited author (261 times of citation), hemorrhagic shock the most frequent keyword (725 times of occurrence), and "traumatic brain injury" the most covered article in keyword clustering (29 articles). The burst analysis revealed Harvard University as the institution with the highest strength value and the Journal of Trauma and Acute Care Surgery the most important journal. It was also concluded that HASAN B ALAM, AARON M WILLIAMS, and LIMIN ZHANG may continue to publish high-quality articles in the future. In the meanwhile, both "protect" and "transfusion" were considered the hotspots and trends in current research. Conclusions The United States has been a major contributor to the publication of the articles over the past 22 years, with the most productive publishing institution, the most cited journal, and the most cited author all coming from the US. Hemorrhagic shock, injury, resuscitation, trauma, models, activation, expression, fluid resuscitation, rats, and nitric oxide are hot topics in relevant research. According to the keyword burst analysis, the areas related to "protect" and "transfusion" may rise as the research directions in the future. However, since the hotspots in the research of hemorrhagic shock are short-lived and fast-changing, the researchers should pay more attention to the development trend in this field.
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Affiliation(s)
- Haoran Ye
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yuan Du
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Yueting Jin
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Fangyu Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing University of Chinese Medicine, Beijing, China
| | - Shasha He
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
| | - Yuhong Guo
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
- Beijing Institute of Traditional Chinese Medicine, Beijing, China
- Beijing Key Laboratory of Basic Research with Traditional Chinese Medicine on Infectious Diseases, Beijing, China
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Schmitt J, Gurney J, Aries P, Danguy Des Deserts M. Advances in trauma care to save lives from traumatic injury: A narrative review. J Trauma Acute Care Surg 2023; 95:285-292. [PMID: 36941236 DOI: 10.1097/ta.0000000000003960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
ABSTRACT Recent advances on trauma management from the prehospital setting to in hospital care led to a better surviving severe trauma rate. Mortality from exsanguination remains the first preventable mortality. Damage-control resuscitation and surgery are evolving and thus some promising concepts are developing. Transfusion toolkit is brought on the prehospital scene while temporary bridge to hemostasis may be helpful. Panel transfusion products allow an individualized ratio assumed by fresh frozen or lyophilized plasma, fresh or cold-stored whole blood, fibrinogen, four-factor prothrombin complex concentrates. Growing interest is raising in whole blood transfusion, resuscitative endovascular balloon occlusion of the aorta use, hybrid emergency room, viscoelastic hemostatic assays to improve patient outcomes. Microcirculation, traumatic endotheliopathy, organ failures and secondary immunosuppression are point out since late deaths are increasing and may deserve specific treatment.As each trauma patient follows his own course over the following days after trauma, trauma management may be seen through successive, temporal, and individualized aims.
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Affiliation(s)
- Johan Schmitt
- From the Intensive Care Unit, Military Teaching Hospital Clermont Tonnerre (S.J., A.P., D.D.D.M.), Brest, France; US Army Institute of Surgical Research (G.J.), San Antonio, Texas; and Joint Trauma System, DoD Center of Excellence for Trauma (G.J.), San Antonio, Texas
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Morgan KM, Abou-Khalil E, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. Association of Prehospital Transfusion With Mortality in Pediatric Trauma. JAMA Pediatr 2023; 177:693-699. [PMID: 37213096 PMCID: PMC10203962 DOI: 10.1001/jamapediatrics.2023.1291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 03/01/2023] [Indexed: 05/23/2023]
Abstract
Importance Optimal hemostatic resuscitation in pediatric trauma is not well defined. Objective To assess the association of prehospital blood transfusion (PHT) with outcomes in injured children. Design, Setting, and Participants This retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT) from January 2009 and December 2019. Interfacility transfers and isolated burn mechanism were excluded. Analysis took place between November 2022 and January 2023. Exposure Receipt of a blood product transfusion in the prehospital setting compared with the emergency department. Main Outcomes and Measures The primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications. Results Of 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age (median [IQR], 47 [9-16] vs 14 [9-17] years), sex (46 [66%] vs 337 [69%] were male), and insurance status (42 [60%] vs 245 [50%]). The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]). Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups. Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications. Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour (adjusted odds ratio, 0.46; 95% CI, 0.23-0.91) and in-hospital mortality (adjusted odds ratio, 0.51; 95% CI, 0.27-0.97) compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10). Conclusions and Relevance In this study, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation. Further prospective studies are warranted. Although the logistics of prehospital blood product programs are complex, strategies to shift hemostatic resuscitation toward the immediate postinjury period should be pursued.
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Prehospital Hemorrhage Control and Treatment by Clinicians: A Joint Position Statement. Ann Emerg Med 2023; 82:e1-e8. [PMID: 37349075 DOI: 10.1016/j.annemergmed.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/10/2023] [Indexed: 06/24/2023]
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Certain L, Rostirola JVC, Pereira JS, Rostirola GC, Estevam BC, Vieira CCA, da Silva I, da Silva JAR, Schevenin JDC, de Oliveira ABR, Franceli AB, Lisboa CEC, Benites BD. First immediate transfusion at a prehospital environment in Latin America: A case report. Hematol Transfus Cell Ther 2023; 45 Suppl 2:S153-S156. [PMID: 34862155 PMCID: PMC10433293 DOI: 10.1016/j.htct.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/10/2021] [Accepted: 08/10/2021] [Indexed: 10/19/2022] Open
Affiliation(s)
- Lucas Certain
- Serviço de Atendimento Móvel de Urgência (SAMU - 192), Bragança Paulista, SP, Brazil.
| | | | | | | | | | | | - Israel da Silva
- Serviço de Atendimento Móvel de Urgência (SAMU - 192), Bragança Paulista, SP, Brazil
| | | | | | | | | | | | - Bruno Deltreggia Benites
- Centro de Hematologia e Hemoterapia, Universidade Estadual de Campinas (Hemocentro Unicamp), Campinas, SP, Brazil
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Morgan CG, Neidert LE, Ozuna KM, Glaser JJ, Pusateri AE, Tiller MM, Cardin S. PREHOSPITAL PLASMA IS NONINFERIOR TO WHOLE BLOOD FOR RESTORATION OF CEREBRAL OXYGENATION IN A RHESUS MACAQUE MODEL OF TRAUMATIC SHOCK AND HEMORRHAGE. Shock 2023; 60:146-152. [PMID: 37179251 DOI: 10.1097/shk.0000000000002148] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
ABSTRACT Introduction: Traumatic shock and hemorrhage (TSH) is a leading cause of preventable death in military and civilian populations. Using a TSH model, we compared plasma with whole blood (WB) as prehospital interventions, evaluating restoration of cerebral tissue oxygen saturation (CrSO 2 ), systemic hemodynamics, colloid osmotic pressure (COP) and arterial lactate, hypothesizing plasma would function in a noninferior capacity to WB, despite dilution of hemoglobin (Hgb). Methods: Ten anesthetized male rhesus macaques underwent TSH before randomization to receive a bolus of O(-) WB or AB(+) plasma at T0. At T60, injury repair and shed blood (SB) to maintain MAP > 65 mm Hg began, simulating hospital arrival. Hematologic data and vital signs were analyzed via t test and two-way repeated measures ANOVA, data presented as mean ± SD, significance = P < 0.05. Results: There were no significant group differences for shock time, SB volume, or hospital SB. At T0, MAP and CrSO 2 significantly declined from baseline, though not between groups, normalizing to baseline by T10. Colloid osmotic pressure declined significantly in each group from baseline at T0 but restored by T30, despite significant differences in Hgb (WB 11.7 ± 1.5 vs. plasma 6.2 ± 0.8 g/dL). Peak lactate at T30 was significantly higher than baseline in both groups (WB 6.6 ± 4.9 vs. plasma 5.7 ± 1.6 mmol/L) declining equivalently by T60. Conclusions: Plasma restored hemodynamic support and CrSO 2 , in a capacity not inferior to WB, despite absence of additional Hgb supplementation. This was substantiated via return of physiologic COP levels, restoring oxygen delivery to microcirculation, demonstrating the complexity of restoring oxygenation from TSH beyond simply increasing oxygen carrying capacity.
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Affiliation(s)
- Clifford G Morgan
- Naval Medical Research Unit San Antonio, JBSA-Ft. Sam Houston, Texas
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45
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Iannaccone A, Reisch B, Kimmig R, Schmidt B, Mavarani L, Darkwah Oppong M, Tyczynski B, Dzietko M, Jahn M, Gellhaus A, Köninger A. Therapeutic Plasma Exchange in Early-Onset Preeclampsia: A 7-Year Monocentric Experience. J Clin Med 2023; 12:4289. [PMID: 37445324 DOI: 10.3390/jcm12134289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/19/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023] Open
Abstract
Different therapeutic apheresis techniques have been clinically tested to delay preterm delivery in the case of eoPE (early-onset preeclampsia). Our study evaluated the feasibility of TPE (therapeutic plasma exchange) compared to standard-of-care treatment. Twenty patients treated with 95 TPE sessions were included in the final analysis and retrospectively matched with 21 patients with comparable placental dysfunction. Gestational age at admission was 23.75 ± 2.26 versus 27.57 ± 2.68 weeks of gestation (WoG) in the control group (p = < 0.001), mean sFlt-1/PlGF ratio was 1946.26 ± 2301.63 versus 2146.70 ± 3273.63 (p = 0.821) and mean sEng was 87.63 ± 108.2 ng/mL versus 114.48 ± 88.78 ng/mL (p = 0.445). Pregnancy was prolonged for 8.25 ± 5.97 days when TPE was started, compared to 3.14 ± 4.57 days (p = 0.004). The median sFlt-1/PlGF Ratio was 1430 before and 1153 after TPE (-18.02%). Median sEng fell from 55.96 ng/mL to 47.62 mg/mL (-27.73%). The fetal survival rate was higher in TPE-treated cases. NICU (Neonatal Intensive Center Unit) stay was in the median of 63 days in the TPE group versus 48 days in the standard-of-care group (p = 0.248). To date, this monocentric retrospective study, reports the largest experience with extracorporeal treatments in eoPE worldwide. TPE could improve pregnancy duration and reduce sFlt-1 and sEng in maternal serum without impairing neonatal outcomes.
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Affiliation(s)
- Antonella Iannaccone
- Department of Gynecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Beatrix Reisch
- Department of Gynecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Rainer Kimmig
- Department of Gynecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Börge Schmidt
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital, University of Duisburg-Essen, 45147 Essen, Germany
| | - Laven Mavarani
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital, University of Duisburg-Essen, 45147 Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Bartosz Tyczynski
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Mark Dzietko
- Department of Pediatrics I, Division of Neonatology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Michael Jahn
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Alexandra Gellhaus
- Department of Gynecology and Obstetrics, University Hospital Essen, University of Duisburg-Essen, 45147 Essen, Germany
| | - Angela Köninger
- Department of Gynecology and Obstetrics, St. Hedwig's Clinic of the Order of St. John, University Regensburg, 93053 Regensburg, Germany
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Salhi RA, Iyengar S, da Silva Bhatia B, Smith GC, Heisler M. How do current police practices impact trauma care in the prehospital setting? A scoping review. J Am Coll Emerg Physicians Open 2023; 4:e12974. [PMID: 37229183 PMCID: PMC10204184 DOI: 10.1002/emp2.12974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 04/08/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
Objective In the United States, police are often important co-responders to 911 calls with emergency medical services for medical emergencies. To date, there remains a lack of a comprehensive understanding of the mechanisms by which police response modifies time to in-hospital medical care for traumatically injured patients. Further, it remains unclear if differentials exist within or between communities. A scoping review was performed to identify studies evaluating prehospital transport of traumatically injured patients and the role or impact of police involvement. Methods PubMed, SCOPUS, and Criminal Justice Abstracts databases were utilized to identify articles. English-language, US-based, peer-reviewed articles published on or prior to March 30, 2022 were eligible for inclusion. Results Of 19,437 articles initially identified, 70 articles were selected for full review and 17 for final inclusion. Key findings included (1) current law enforcement practices involving scene clearance introduce the potential for delayed patient transport but to date there is little research quantifying delays; (2) police transport protocols may decrease transport times; and (3) there are no studies examining the potential impact of scene clearance practices at the patient or community level. Conclusions Our results highlight that police are often the first on scene when responding to traumatic injuries and have an active role via scene clearance or, in some systems, patient transport. Despite the significant potential for impact on patient well-being, there remains a paucity of data examining and driving current practices.
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Affiliation(s)
- Rama A. Salhi
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Sonia Iyengar
- University of Michigan Medical SchoolAnn ArborMichiganUSA
| | | | - Graham C. Smith
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Washtenaw/Livingston Medical Control AuthorityAnn ArborMichiganUSA
| | - Michele Heisler
- Department of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
- Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborMichiganUSA
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Latif RK, Clifford SP, Baker JA, Lenhardt R, Haq MZ, Huang J, Farah I, Businger JR. Traumatic hemorrhage and chain of survival. Scand J Trauma Resusc Emerg Med 2023; 31:25. [PMID: 37226264 DOI: 10.1186/s13049-023-01088-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.
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Affiliation(s)
- Rana K Latif
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA.
- Paris Simulation Center, Office of Medical Education, University of Louisville School of Medicine, Louisville, KY, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Sean P Clifford
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jeffery A Baker
- Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rainer Lenhardt
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Mohammad Z Haq
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
- Department of Cardiovascular & Thoracic Surgery, Cardiovascular Innovation Institute, University of Louisville, Louisville, KY, USA
- The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA
- Division of Infectious Diseases, Department of Medicine, Center of Excellence for Research in Infectious Diseases (CERID), University of Louisville, Louisville, KY, USA
| | - Ian Farah
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jerrad R Businger
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
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Du Z, Wang T. A bibliometric analysis of publications on trauma-related hemorrhagic shock from 2012 to 2022: Research landscape and future trends. Medicine (Baltimore) 2023; 102:e33814. [PMID: 37335729 DOI: 10.1097/md.0000000000033814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
Trauma-related hemorrhagic shock is a global problem. This study aimed to analyze the knowledge domain and frontiers of trauma-related hemorrhagic shock research through a bibliometric analysis. Articles on trauma-related hemorrhagic shock published between 2012 and 2022 were retrieved from the Web of Science Core Collection, and a bibliometric analysis was conducted using CiteSpace and VOSviewer. A total of 3116 articles and reviews were analyzed. These publications primarily came from 441 institutions in 80 countries, with the USA having the highest number of publications, followed by China. Among the publications, Ernest E. Moore published the most papers, whereas John B. Holcomb had the most co-citations. The most productive institution was the University of Pittsburgh in the USA. The keyword burst and reference clustering analysis indicated that "reboa," "whole blood," "exsome," "glycocalyx," "endotheliopathy," and "predictor" are new trends and developing areas of interest. With the help of CiteSpace and VOSviewer, this study provides a deeper understanding of the research landscape, frontier hotspots, and future trends in trauma-related hemorrhagic shock over the last decade. "Whole blood" instead of "component therapy" shows potential advantage while "REBOA" is increasingly discussed in rapid hemostasis. This study provides important clues for researchers to understand the knowledge domain and frontiers of this study field.
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Affiliation(s)
- Zhe Du
- Trauma Center, Peking University People's Hospital, National Center for Trauma Medicine, Key Laboratory of Trauma and Neural Regeneration (Ministry of Education), Beijing, China
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49
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Dutton RP, Varon AJ. Five Decades of Trauma Anesthesiology. Anesth Analg 2023; 136:949-956. [PMID: 37058732 DOI: 10.1213/ane.0000000000006099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
We present a brief history of the scientific and educational development of trauma anesthesiology. Key milestones from the past 50 years are noted, as well as the current standing of the subspecialty and prospects for the future.
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Affiliation(s)
- Richard P Dutton
- From the Department of Anesthesiology, Texas A&M College of Medicine, Dallas, Texas
| | - Albert J Varon
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine/Ryder Trauma Center, Miami, Florida
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von Vopelius-Feldt J, Lockwood J, Mal S, Beckett A, Callum J, Greene A, Grushka J, Khandelwal A, Lin Y, Nahirniak S, Pavenski K, Peddle M, Prokopchuk-Gauk O, Regehr J, Schmid J, Shih AW, Smith JA, Trojanowski J, Vu E, Ziesmann M, Nolan B. Development of a national out-of-hospital transfusion protocol: a modified RAND Delphi study. CMAJ Open 2023; 11:E546-E559. [PMID: 37369521 DOI: 10.9778/cmajo.20220151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Early resuscitation with blood components or products is emerging as best practice in selected patients with trauma and medical patients; as a result, out-of-hospital transfusion (OHT) programs are being developed based on limited and often conflicting evidence. This study aimed to provide guidance to Canadian critical care transport organizations on the development of OHT protocols. METHODS The study period was July 2021 to June 2022. We used a modified RAND Delphi process to achieve consensus on statements created by the study team guiding various aspects of OHT in the context of critical care transport. Purposive sampling ensured representative distribution of participants in regard to geography and relevant clinical specialties. We conducted 2 written survey Delphi rounds, followed by a virtual panel discussion (round 3). Consensus was defined as a median score of at least 6 on a Likert scale ranging from 1 ("Definitely should not include") to 7 ("Definitely should include"). Statements that did not achieve consensus in the first 2 rounds were discussed and voted on during the panel discussion. RESULTS Seventeen subject experts participated in the study, all of whom completed the 3 Delphi rounds. After the study process was completed, a total of 39 statements were agreed on, covering the following domains: general oversight and clinical governance, storage and transport of blood components and products, initiation of OHT, types of blood components and products, delivery and monitoring of OHT, indications for and use of hemostatic adjuncts, and resuscitation targets of OHT. INTERPRETATION This expert consensus document provides guidance on OHT best practices. The consensus statements should support efficient and safe OHT in national and international critical care transport programs.
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Affiliation(s)
- Johannes von Vopelius-Feldt
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man.
| | - Joel Lockwood
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Sameer Mal
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Andrew Beckett
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jeannie Callum
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Adam Greene
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jeremy Grushka
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Aditi Khandelwal
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Yulia Lin
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Susan Nahirniak
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Katerina Pavenski
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Michael Peddle
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Oksana Prokopchuk-Gauk
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Julian Regehr
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jo Schmid
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Andrew W Shih
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Justin A Smith
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Jan Trojanowski
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Erik Vu
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Markus Ziesmann
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
| | - Brodie Nolan
- Ornge (von Vopelius-Feldt, Lockwood, Mal, Peddle, Smith, Nolan), Mississauga, Ont.; Department of Emergency Medicine (von Vopelius-Feldt, Lockwood, Nolan), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Division of Emergency Medicine (Mal, Peddle), London Health Sciences Centre, London, Ont.; Department of Surgery, Trauma and Acute Care Surgery (Beckett), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Canadian Forces Health Services Headquarters (Beckett, Schmid), Canadian Armed Forces, Ottawa, Ont.; Department of Pathology and Molecular Medicine (Callum), Kingston Health Sciences Centre and Queen's University, Kingston, Ont.; University of Toronto Quality in Utilization, Education and Safety in Transfusion (QUEST) research program (Callum, Khandelwal, Pavenski), Toronto, Ont.; AirEvac and Critical Care Operations (Greene, Vu), British Columbia Emergency Health Services, Vancouver, BC; School of Medicine (Greene), Cardiff University, Cardiff, Wales, UK; Division of Trauma and General Surgery (Grushka), McGill University Health Centre, Montreal General Hospital Site, Montréal, Que.; Canadian Blood Services (Khandelwal); Department of Laboratory Medicine and Pathobiology (Lin), University of Toronto; Precision Diagnostics and Therapeutics Program (Lin), Sunnybrook Health Sciences Centre, Toronto, Ont.; Faculty of Medicine (Nahirniak), University of Alberta, Edmonton, Alta.; Transfusion and Transplantation Medicine (Nahirniak), Alberta Precision Laboratories, Calgary, Alta.; Departments of Medicine and Laboratory Medicine (Pavenski), St. Michael's Hospital, Unity Health Toronto and University of Toronto, Toronto, Ont.; Division of Transfusion Medicine (Prokopchuk-Gauk), Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority; College of Medicine (Prokopchuk-Gauk), University of Saskatchewan, Saskatoon, Sask.; Emergency Department (Regehr), Health Sciences Centre; Shock Trauma Air Rescue Service (STARS) (Regehr), Manitoba Base, Winnipeg, Man.; Department of Pathology and Laboratory Medicine (Shih), Vancouver Coastal Health Authority; Centre for Blood Research (Shih), University of British Columbia; Department of Emergency Medicine (Trojanowski), Vancouver General Hospital and the University of British Columbia; Clinical Operations (Trojanowski), British Columbia Emergency Health Services; Departments of Emergency Medicine and Critical Care Medicine (Vu), Vancouver Coastal Health Authority and Provincial Health Services Authority, Vancouver, BC; Department of Surgery and Section of Critical Care (Ziesmann), Health Sciences Centre, Winnipeg, Man
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