[The damage control resuscitation concept]

Massive transfusion triggers in severe trauma: Scoping review

OBJECTIVE

to identify the predictive variables or the massive transfusion triggers in severely traumatized patients through the existing scales.

METHOD

a review of the literature was carried out using the Scoping Review method across the electronic databases CINAHL, MEDLINE, LILACS, the Cochrane and IBECS libraries, and the Google Scholar search tool.

RESULTS

in total, 578 articles were identified in the search and the 36 articles published in the last ten years were included, of which 29 were original articles and 7 review articles. From the analysis, scales for massive transfusion and their predictive triggers were examined.

CONCLUSION

the absence of universal criteria regarding the massive transfusion triggers in traumatized patients has led to the development of different scales, and the studies on their validation are considered relevant for the studies about when to initiate this strategy.

Accidental hypothermia in severe trauma

Hypothermia, along with acidosis and coagulopathy, is part of the lethal triad that worsen the prognosis of severe trauma patients. While accidental hypothermia is easy to identify by a simple measurement, it is no less pernicious if it is not detected or treated in the initial phase of patient care. It is a multifactorial process and is a factor of mortality in severe trauma cases. The consequences of hypothermia are many: it modifies myocardial contractions and may induce arrhythmias; it contributes to trauma-induced coagulopathy; from an immunological point of view, it diminishes inflammatory response and increases the chance of pneumonia in the patient; it inhibits the elimination of anaesthetic drugs and can complicate the calculation of dosing requirements; and it leads to an over-estimation of coagulation factor activities. This review will detail the pathophysiological consequences of hypothermia, as well as the most recent principle recommendations in dealing with it.

Blast injury: impact on brain and internal organs

Blast trauma can kill or injure by multiple different mechanisms, not all of which may be obvious on initial presentation. Patients injured by blast effects should be treated as having multisystem trauma and managed according to Advanced Trauma Life Support guidelines. For the most severely injured patients, damage control resuscitation should be practiced until definitive hemorrhage control has been achieved. Patients with blast injuries may present in mass-casualty episodes that can overwhelm local resources. This article reviews some specific injuries, as well as the importance of mild traumatic brain injury. The importance of rehabilitation is discussed.

[Out-of-hospital equipment of emergency medical services for hemorrhagic shock management: can do better!]

INTRODUCTION

Hemorrhagic shock is an emergency, which may benefit from a medicalized prehospital care. Our goal was to survey the means available in the 370 French prehospital medicalized emergency services (SMUR) for hemorrhagic situations.

METHODS

Multicenter descriptive observational study by email then phone with all the 370 French SMUR leaders. The questionnaire was created by investigators of the project through a Delphi method, and was about service protocols concerning hemorrhagic patient care, hemorrhagic parameters measure equipment available, intravenous solutes and drugs as well as various medical devices useful or perceived to be useful to support prehospital hemorrhagic shock. The results are expressed in numbers and percentages.

RESULTS

The overall response rate was 48% (n=178). Protocols were established in between 43% (n=76) and 47% (n=83) according to etiology, measuring devices were available in 5% (n=9) of the Smur for hemostasis up to 89% (n=158) for hemoglobin measurement. Available intravenous solutes were mainly isotonic salty serum (95%, n=169), hydroxylethylstarch (83%, n=148) and Ringer lactate (73%, n=130). Tranexamic acid was available in 84 (47%) Smur. The teams had access to erythrocytes concentrates, fresh frozen plasma and platelets in 84% (n=150), 44% (n=79) and 23% (n=41) respectively. Eighty-one (46%) Smur had tourniquets and 127 (71%) anti-shock trousers. Finally, 57 (32%) had a pelvic restraint belt.

CONCLUSION

There is a great disparity in the means available in the French Smur for the support of prehospitalization bleeding. The majority the Smur physicians can transfuse in a prehospital setting. On the other hand, a minority of teams can actively warm patients, employ tranexamic acid or use pelvic restraint belts.

[The initial management in intensive care of pelvic ring injury patients]

Pelvic trauma care is complex since it is frequently associated with multiple injuries and may lead to dramatic and uncontrollable haemorrhage. After pelvic trauma, the mortality, around 8 to 10%, is mainly related to severe pelvic hemorrhage but also to extrapelvic injuries (thoracic, abdominal or brain injuries). It is therefore crucial to manage pelvic trauma in specialized trauma center. The initial trauma assessment aims to determine the role of the pelvic injury in hemorrhage to define the therapeutic strategy of pelvic trauma care (arterial embolisation/pelvic ring stabilisation). This review was performed with a systematic review of the literature; it describes the pelvic fracture pathophysiology, and the efficacy and safety of haemostatic procedures and with their respective indications. A decision making algorithm is proposed for the treatment of trauma patients with pelvic fracture.

[Blood transfusion on battlefield. The Kabul hospital experience]

OBJECTIVES

Blood transfusion is an aspect of medical care on the battlefield. French assets include: red blood cell units (RBCu), lyophilized plasma (PLYO), fresh whole blood (FWB) but neither fresh-frozen plasma (FFP) nor platelets. French transfusion strategy in military operations follows the evolution of knowledge and resources. We describe the characteristics of the transfusion at the military hospital in Kabul.

PATIENTS AND METHODS

Retrospective study of records of patients transfused between October 2010 to December 2011 conducted in Kabul from transfusion register. Variables studied were: patient characteristics, biology at admission, type and amount of transfusion products, evolution.

RESULTS

One hundred and twenty-six patients were transfused: 49 military (39%) which 22 French soldier (17%), most of time afghan (n=97; 77%), mean age at 24 years old (3-66). Two hundred and seventy-three RBCu from France were transfused and 350 unused were destroyed. Conditions leading to a transfusion were: 76 war wounds (60%), 21 trauma (17%) and 29 other (23%). In the first 24 hours, patients received in mean: two RBCu (0-12), one unit of FWB (0-18) and two PLYO (0-14). PLYO/RBCu ratio was 1/1.6. A massive transfusion (more than 10 RBCu) concerned 9% of patients. Twenty-seven percent of patients received FWB. We note 17 dead people (13.5%).

CONCLUSION

The use of the FWB and PLYO in substitution of FFP and platelets can provide cares of high quality in a logistically constrained context while controlling costs.

[Damage control applied to severe maxillofacial trauma]

Damage control is defined by the extreme emergency implementation of a first resuscitation and surgical step, during which there is no attempt at repairing lesions but only at restoring adequate physiological function. In recent years, "damage control" has considerably improved the management of polytrauma patients, especially in war surgery. Respiratory distress or hemorrhagic shock requirements are critical maxillofacial emergencies. We present the specificities of "damage control" management for patients with severe maxillofacial trauma. Some clinical and biological criteria have been defined to choose "damage control" strategy, in patients presenting with life-threatening facial hemorrhage after facial trauma. A rapid initial stage restores vital functions. Airways are maintained and secured: oro-tracheal intubation, cricothyroidotomy, surgical tracheotomy. Facial bleeding is controlled with various means: oronasal packing, angiographic embolization, selective ligation then external carotid artery if necessary. The resuscitation step stabilizes the lethal triad: hypothermia, coagulopathy, metabolic acidosis. The second step that comes in later is a surgical repair of facial injuries. "Damage control" can be adequately applied to the management of patients with severe maxillofacial trauma.

The evolution of damage control surgery

The philosophy of damage control surgery has developed tremendously over the past 10 years. It has expanded outside the original boundaries of the abdomen and has been applied to all aspects of trauma care, ranging from resuscitation to limb-threatening vascular injuries. In recent years, the US military has taken the concept to a new level by initiating a damage control approach at the point of injury and continuing it through a transcontinental health care system. This article highlights many recent advances in damage control surgery and discusses proper patient selection and the risks associated with this management strategy.