Diagnostic performance of serial haematocrit measurements in identifying major injury in adult trauma patients

Control of Haemorrhage in Orthopaedic Trauma

This paper aims to outline current practices and examine promising new advancements in the modern management of haemorrhage in orthopaedic trauma. Many prehospital and perioperative haemorrhage control strategies and techniques have been available to clinicians for multiple decades, yet our understanding and utilisation of these practices continues to be refined and optimised. There is a particular focus in this article on issues related to resuscitation and coagulation in trauma. We examine the complex mechanisms that lead to coagulopathy in trauma patients as well as the transformative effect tranexamic acid has had in limiting blood loss. We also explore some emerging technologies such as endovascular interventions and clot-stabilising dressings and devices that are likely to have a significant impact going forward.

Hematocrit and lactate trends help predict outcomes in trauma independent of CT and other clinical parameters

Background

Hematocrit and lactate have an established role in trauma as indicators of bleeding and cell death, respectively. The wide availability of CT imaging and clinical data poses the question of how these can be used in combination to predict outcomes.

Purpose

To assess the utility of hematocrit or lactate trends in predicting intensive care unit (ICU) admission and hospital length of stay (LOS) in patients with torso trauma combined with clinical parameters and injury findings on CT.

Materials and Methods

This was a single-center retrospective study of adults with torso trauma in one year. Trends were defined as a unit change per hour. CT findings and clinical parameters were explanatory variables. Outcomes were ICU admission and hospital LOS. Multivariate logistic and negative binomial regression models were used to calculate the odds ratio (OR) and incident rate ratio (IRR).

Results

Among 840 patients, 561 (72% males, age 39 ± 18) were included, and 168 patients (30%) were admitted to the ICU. Decreasing hematocrit trend [OR 2.54 (1.41-4.58), p = 0.002] and increasing lactate trend [OR 3.85 (1.35-11.01), p = 0.012] were associated with increased odds of ICU admission. LOS median was 2 (IQR: 1-5) days. Decreasing hematocrit trend [IRR 1.37 (1.13-1.66), p = 0.002] and increasing lactate trend [2.02 (1.43-2.85), p < 0.001] were associated with longer hospital LOS.

Conclusion

Hematocrit and lactate trends may be helpful in predicting ICU admission and LOS in torso trauma independent of organ injuries on CT, age, or admission clinical parameters.

Impairment of Mesenteric Perfusion as a Marker of Major Bleeding in Trauma Patients

The majority of potentially preventable mortality in trauma patients is related to bleeding; therefore, early recognition and effective treatment of hemorrhagic shock impose a cardinal challenge for trauma teams worldwide. The reduction in mesenteric perfusion (MP) is among the first compensatory responses to blood loss; however, there is no adequate tool for splanchnic hemodynamic monitoring in emergency patient care. In this narrative review, (i) methods based on flowmetry, CT imaging, video microscopy (VM), measurement of laboratory markers, spectroscopy, and tissue capnometry were critically analyzed with respect to their accessibility, and applicability, sensitivity, and specificity. (ii) Then, we demonstrated that derangement of MP is a promising diagnostic indicator of blood loss. (iii) Finally, we discussed a new diagnostic method for the evaluation of hemorrhage based on exhaled methane (CH₄) measurement. Conclusions: Monitoring the MP is a feasible option for the evaluation of blood loss. There are a wide range of experimentally used methodologies; however, due to their practical limitations, only a fraction of them could be integrated into routine emergency trauma care. According to our comprehensive review, breath analysis, including exhaled CH₄ measurement, would provide the possibility for continuous, non-invasive monitoring of blood loss.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

The Utility of Serial Hemoglobin Monitoring in Non-Operative Management of Blunt Splenic Injury

BACKGROUND

The Eastern Association for the Surgery of Trauma (EAST) states there is not enough evidence to recommend a particular frequency of measuring Hgb values for non-operative management (NOM) of blunt splenic injury (BSI). This study was performed to compare the utility of serial Hgb (SHgb) to daily Hgb (DHgb) in this population.

METHODS

We conducted a retrospective chart review of patients with BSI between 2013 and 2019. Demographics, comorbidities, lab values, clinical decisions, and outcomes were gathered through a trauma database.

RESULTS

A total of 562 patients arrive in the trauma bay with BSI. In the NOM group, 297 were successful and 37 failed NOM. Of those that failed NOM, 8 (21.6%) changed to OM due to a drop in Hgb. 5 (62.5%) were hypotensive first, 2 (25%) were no longer receiving SHgb, and 1 (12.5%) had a repeat CT scan and was embolized. DHgb patients were not significantly different from SHgb patients in injury severity, length of stay, the largest drop in Hgb, and incidence of failing NOM. Patients taking aspirin were more likely to fall below 7 g/dl at 48 and 72 hours into admission.

CONCLUSIONS

These results suggest that that trending SHgb may not influence clinical decision-making in NOM of BSI. Besides taking aspirin, risk factors for who would benefit from SHgb were not identified. Patients who received DHgb had similar injuries and outcomes than patients who received SHgb. Prospective studies are needed to evaluate the clinical utility of SHgb compared to DHgb.

Tertiary survey ultrasound has no diagnostic benefit in trauma patients without abdominal injuries on standardised initial whole-body computed tomography

PURPOSE

The aim of our study was to evaluate the impact of a routine tertiary survey ultrasound (US) on patient management in major trauma patients without trauma-related abdominal findings on standardised initial whole-body CT (WBCT).

METHODS

In this retrospective study, all WBCT scans acquired in major trauma patients between 07/2017 and 12/2019 at a university hospital and level I trauma centre were screened. 1,024 patients were included in the final analysis. Results of tertiary survey US and patient information (demographic data, trauma mechanism, imaging findings, clinical course, medical history, and anticoagulative medication) were collected and analysed.

RESULTS

Routine tertiary survey US revealed new abdominal findings in six out of 1,024 patients (0.6%). None of the patients had to undergo surgery or minimally invasive intervention, nor did any of the patients die as a result of abdominal injuries. Additional abdominal imaging after tertiary survey US was ordered in 39 patients (38 US, 1 US + CT). None of these patients required further treatment for abdominal injuries.

CONCLUSIONS

Routine tertiary survey US after inconspicuous standardised initial WBCT did not change clinical outcome for abdominal trauma patients.

Change in Hematocrit during Trauma Assessment Predicts Bleeding Even with Ongoing Fluid Resuscitation

This study tests the hypothesis that a change in hematocrit (ΔHct) during initial trauma work-up is as reliable as conventional vital signs for detecting bleeding, even with ongoing fluid resuscitation. Consecutive trauma patients admitted to a Level I trauma center receiving two Hct measurements during initial resuscitation between January 2010 and January 2011 were stratified based on estimated blood loss greater than 250 mL (bleeding) or nonbleeding. Sensitivity, specificity, and receiver operating characteristic curves were calculated for systolic blood pressure (SBP), heart rate, base deficit, and ΔHct. In 168 (72%) nonbleeding versus 64 (28%) bleeding patients, age and gender were similar. Arrival SBP was highly specific (90 to 99%) but poorly sensitive (13 to 31%) for detecting bleeding. Combinations of vital signs increased specificity, albeit at the expense of sensitivity. For bleeding versus nonbleeding patients (all receiving resuscitation fluid), ΔHct was 9.0 versus 1.8, ΔHct/liter was 4.8 versus 1.5, and ΔHct/liter/hour was 2.8 vs 0.6 (all P < 0.001). Only SBP (area under the curve [AUC] 0.608 to 0.695) and ΔHct (AUC 0.731 to 0.921) were significant for identifying bleeding with ΔHct 6 or greater being the best predictor (sensitivity 89%, specificity 95%, AUC 0.921). During ongoing fluid resuscitation of a trauma victim, ΔHct is the single most reliable indicator of continuing blood loss. A ΔHct 6 or greater during initial resuscitation is highly suspicious for ongoing blood loss, but even lesser changes have predictive value. Altogether, these results support the idea that fluid shifts are rapid after hemorrhage and Hct can be valuable during initial trauma assessment.

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition

BACKGROUND

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated.

RESULTS

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Are serial hematocrit measurements sensitive enough to predict intra-abdominal injuries in blunt abdominal trama?

Objective

Routine serial hematocrit measurements are a component of the trauma evaluation for patients without serious injury identified on initial evaluation. We sought to determine whether serial hematocrit testing was useful in predicting the probable injuries in blunt abdominal trauma.

Materials and method

We performed a prospective study of trauma patients admitted in our observation unit over a 12-month period. Patients routinely underwent serial hematocrit testing in 6-hour intervals (two hematocrit levels). We compared trauma patients with a hematocrit drop of 5 and 10 points or more to those without a significant hematocrit drop.

Results

Five hundred forty-two isolated blunt abdominal trauma patients were admitted to observation unit, and 468 patients (86.35%) had serial hematocrit during their 6-hour stay. Of these patients, 36.11% had a hematocrit drop of 5 or more and 12.61% a drop of 10 or more. Of patients with the hematocrit drop >10, 50.8% have had diagnostic manifestations of intra-abdominal injury in both ultrasonographic and computed tomography scanning (P<0.001). There was no significant correlation between hematocrit drop >5 and positive imaging.

Conclusion

Although serial hematocrit testing may be useful in specific situations, routine use of serial hematocrit testing in trauma patients at a level I trauma center’s observation unit did not significantly aid in the prediction of occult injuries.

Using Serial Hemoglobin Levels to Detect Occult Blood Loss in the Early Evaluation of Blunt Trauma Patients

BACKGROUND

Serial hemoglobin measurement (ΔHgb) is intended to aid in the early identification of blunt trauma patients who have significant blood loss requiring intervention. However, the utility of ΔHgb has yet to be rigorously studied.

OBJECTIVE

We sought to determine if ΔHgb is a reliable diagnostic tool in assessing blood loss in blunt trauma patients.

METHODS

We enrolled consecutive blunt trauma patients ≥18 years of age who presented to a level I trauma center. We measured 2 hemoglobin levels spaced 5 min apart and calculated the difference (ΔHgb) for each patient. We also recorded whether each patient required any of the following interventions to treat their injuries: 1) operation or procedure to control hemorrhage; 2) radiographic embolization; 3) administration of blood and blood products; 4) administration of ≥3 liters of intravenous fluids; and 5) exsanguination. Our primary outcome was the area under the receiver operating characteristic (ROC) curve.

RESULTS

We enrolled 251 patients, including 192 males and 59 females with a mean age of 40 years. Interventions occurred in 56 patients and were withheld in 195. The median ΔHgb was -0.1 gm/dL (interquartile range -0.5 to 0.1 gm/dL) for patients requiring intervention and 0.0 gm/dL (interquartile range -0.6 to 0.3 gm/dL) for patients not requiring intervention. We found the area under the ROC curve to be 0.53 (95% confidence interval 0.44-0.62).

CONCLUSIONS

Our results indicated that ΔHgb does not reliably distinguish between blunt trauma patients who require intervention and those who do not.

How useful are hemoglobin concentration and its variations to predict significant hemorrhage in the early phase of trauma? A multicentric cohort study

Background

The diagnostic value of hemoglobin (Hb) for detecting a significant hemorrhage (SH) in the early phase of trauma remains controversial. The present study aimed to assess the abilities of Hb measurements taken at different times throughout trauma management to identify patients with SH.

Methods

All consecutive adult trauma patients directly admitted to six French level-1 trauma centers with at least one prehospital Hb measurement were analyzed. The abilities of the following variables to identify SH (≥ 4 units of red blood cells in the first 6 h and/or death related to uncontrolled bleeding within 24 h) were determined and compared to that of shock index (SI): Hb as measured with a point-of-care (POC) device by the prehospital team on scene (POC-Hb_prehosp) and upon patient’s admission to the hospital (POC-Hb_hosp), the difference between POC-Hb_hosp and POC-Hb_prehosp (DeltaPOC-Hb) and Hb as measured by the hospital laboratory on admission (Hb-Lab_hosp).

Results

A total of 6402 patients were included, 755 with SH and 5647 controls (CL). POC-Hb_prehosp significantly predicted SH with an area under ROC curve (AUC) of 0.72 and best cutoff values of 12 g/dl for women and 13 g/dl for men. POC-Hb_prehosp < 12 g/dl had 90% specificity to predict of SH. POC-Hb_hosp and Hb-Lab_hosp (AUCs of 0.92 and 0.89, respectively) predicted SH better than SI (AUC = 0.77, p < 0.001); best cutoff values of POC-Hb_hosp were 10 g/dl for women and 12 g/dl for men. DeltaPOC-Hb also predicted SH with an AUC of 0.77, a best cutoff value of − 2 g/dl irrespective of the gender. For a same prehospital fluid volume infused, DeltaPOC-Hb was significantly larger in patients with significant hemorrhage than in controls.

Conclusions

Challenging the classical idea that early Hb measurement is not meaningful in predicting SH, POC-Hb_prehosp was able, albeit modestly, to predict significant hemorrhage. POC-Hb_hosp had a greater ability to predict SH when compared to shock index. For a given prehospital fluid volume infused, the magnitude of the Hb drop was significantly higher in patients with significant hemorrhage than in controls.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0420-8) contains supplementary material, which is available to authorized users.

Lactate as an Early Predictor for Early Massive Transfusion in Trauma Patients: A Retrospective Study

Objective

Transfusion is a key treatment for patients with hemorrhage. Early massive transfusion (EMT) is defined as transfusion of 10 or more units of red blood cells (RBC) within the first 6 hours. We attempted to determine whether metabolic markers can be used as predictors for EMT.

Method

We retrospectively reviewed outcomes in 71 patients who visited the emergency department within 12 hours after trauma and received at least 1 unit of RBC within 24 hours between January 2008 and June 2010.

Results

Of the 71 patients, 54 were male and 17 were female; their mean age was 50.3±17.7 years. Of these, 15 required EMT and 56 did not; these patients received 17.7±13.1 and 2.8±2.3 units of RBCs, respectively. There were significant differences between EMT and non-EMT groups in injury severity score (ISS; p=0.001), systolic blood pressure (SBP; p=0.010), base deficit (p=0.003), and lactate concentration (p=0.001). Logistic regression analysis showed that SBP <90 mmHg (odds ratio [OR] 11.71, 95% CI 1.83-74.77, p=0.009), ISS ≥25 (OR 23.39, 95% CI 1.87-293.23, p=0.015), and lactate ≥3.5 mmol/L (OR 6.99, 95% CI 1.10-44.33, p=0.039) were significant predictors of EMT. The area under the curve for ≥3.5 mmol/L lactate was 0.79 (p=0.001), with a sensitivity of 76.7% and a specificity of 67.8%. The 30-day mortality rate was significantly higher in patients with lactate ≥3.5 mmol/L than in those with lactate <3.5 mmol/L (p=0.002).

Conclusion

Lactate concentration is an important predictor of the need for EMT and should be considered in the initial phase of trauma resuscitation to prepare for massive transfusion.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Admission hematocrit predicts the need for transfusion secondary to hemorrhage in pediatric blunt trauma patients

BACKGROUND

Pediatric trauma uses a substantial amount of resources. Quick and cost-effective measures that can be used to identify children with clinically relevant injuries are essential to resource allocation and optimization of patient care. Admission hematocrit is rapid and inexpensive, causes minimal harm, and can potentially aid in critical decision making. We hypothesize that admission hematocrit predicts the need for transfusion in pediatric blunt trauma patients.

METHODS

Records of trauma patients age 0 year to 17 years (2005-2013) who presented to a pediatric Level 1 trauma center were retrospectively reviewed. Data collected include demographics, computed tomographic scan findings, need for an intervention secondary to bleeding (blood transfusion, angioembolization, or operation), and admission hematocrit.

RESULTS

We found a significant decrease in admission hematocrit between patients requiring a transfusion and patients who did not (27% vs. 36%, p < 0.01). We evaluated a subset of patients who had an abdominal computed tomographic scan and found a significant decrease in admission hemocrit between those who required a transfusion for an intra-abdominal injury and those who did not (29% vs 37%, p < 0.01). In this subset, serial hematocrit values remained significantly lower in the patients requiring a transfusion up to 67 hours after admission (p = 0.04). A cutoff admission hematocrit of 35% or less has a sensitivity of 94% and a negative predictive value of 99.9% in identifying children who need a transfusion after blunt trauma.

CONCLUSION

An admission hematocrit of 35% or less provides a reliable screening test because of its low false negative rate and high specificity for identifying patients at an increased risk of bleeding after injury. Admission hematocrit could be widely implemented to identify patients who may need a transfusion with low expense and minimal harm for our pediatric patients and may be able to alter the entire course of their trauma resuscitation.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III.

Rectus sheath hematoma: a review of the literature

Rectus sheath hematoma (RSH) is a relatively rare clinical condition, strongly associated among others, with abdominal trauma and anticoagulation. Although well documented over the years, it still seems to be often misdiagnosed. Estimations of further increase in incidence are made, based on the increasing use of anticoagulants. Thus it was of interest to us to perform a literature review on the available literature of this entity with the aim to facilitate a better understanding and management in primary and secondary care settings. This review intends to present a synthesis on the main topics of this condition such as pathophysiology, epidemiology, predisposing factors, clinical presentation, diagnosis and basic treatment instructions. The initial search resulted in 146 articles. Additional citations from the reference list of the relevant publication were also included. Every physician in the field of primary/emergency medicine and surgery must be familiar with it, as misdiagnosis may lead to unnecessary laparotomy or death. In contrast, faster and more accurate diagnosis can lead to mortality rate reduction and cost containment.

Splenic Doppler resistive index for early detection of occult hemorrhagic shock after polytrauma in adult patients

The objective of this study was to evaluate whether direct assessment of splenic circulation by splenic Doppler resistive index (Doppler RI) is a clinically useful noninvasive method for an early detection of occult hemorrhagic shock after polytrauma in adult patients. Splenic Doppler RI was measured in 49 hemodynamically stable adult patients admitted to the emergency department because of polytrauma. Renal Doppler RI was also determined in 20 patients. Spleen size, Injury Severity Score, systolic blood pressure, heart rate, blood lactate, standard base excess, pH, hemoglobin, and inferior vena cava diameter values were recorded at admission and at 24 h. Patients were grouped according to whether signs of hemorrhagic shock did (n = 22) or did not (n = 27) occur within the first 24 h from admission. Patients who developed hemorrhagic shock had significantly higher splenic and renal Doppler RI, higher Injury Severity Score, and lower standard base excess at admission. By multivariate logistic regression, splenic Doppler RI resulted to be a predictor of hemorrhagic shock development within the first 24 h from admission. Splenic Doppler RI may represent a clinically useful noninvasive method for early detection of occult hemorrhagic shock and persistent occult hypoperfusion after polytrauma in adult patients.

Management of bleeding following major trauma: an updated European guideline

INTRODUCTION

Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature.

RESULTS

Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies.

CONCLUSIONS

This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.

Serial hematocrit testing does not identify major injuries in trauma patients in an observation unit

BACKGROUND

Routine serial hematocrit measurements are a component of the trauma evaluation for patients without serious injury identified on initial evaluation. We sought to determine whether serial hematocrit testing was useful in detecting significant intra-abdominal injuries in trauma patients in our observation unit.

METHODS

We performed a retrospective chart review of all trauma patients placed in our observation unit over a 14-month period. Patients had received trauma surgery evaluation before placement in the observation unit and routinely received serial hematocrit testing (>or=2 hematocrit levels) while in the observation unit. We compared trauma patients with a hematocrit drop of 5 points or more to those without a significant hematocrit drop.

RESULTS

Three hundred sixty-five trauma patients were placed in the observation unit, and 310 patients (85%) had at least 2 hematocrits drawn during their stay. Of these patients, 20.6% had a hematocrit drop of 5 or more. Of patients with the hematocrit change, 18.8% were admitted to an inpatient unit from the observation unit compared to 9.3% of patients without a significant hematocrit change (P = .034). In one of these patients who had a computed tomography scan before observation admission, which demonstrated free fluid, the hematocrit drop assisted in diagnosing significant intra-abdominal injury.

CONCLUSION

Although serial hematocrit testing may be useful in specific situations, routine use of serial hematocrit testing in trauma patients at a level I trauma center's observation unit did not significantly aid in the detection of occult injury.

[Management of hemorrhage in patients with abdominal trauma: application of the European Guidelines for the management of bleeding following major trauma]

In patients with traumatic intraabdominal hemorrhage, urgent decisions must be made. Resuscitation measures must often be simultaneously combined with diagnostic actions and measures to control the source of the bleeding. Hemorrhages are usually complicated by coagulation disorders and the presence of acidosis and hypothermia. In these conditions, emergency measures are required that usually involve various specialists. However, given the paucity of the scientific evidence in this field, the intervention protocols differ from one center to another. The European Guidelines for the management of bleeding following major trauma has recently been published. These guidelines review aspects such as evaluation and initial management of bleeding, localization and control of the source of bleeding and replacement of blood products. In addition, recommendations based on the best available evidence to 2008 are made. This review describes the basic aspects of traumatic intraabdominal hemorrhage.

Pediatric major trauma: an approach to evaluation and management

Trauma is the leading cause of death in children nationwide. Proper management of the pediatric trauma patient involves many of the components contained within standard trauma protocols. By paying strict attention to the anatomical and physiological differences in the pediatric population, clinicians will be assured the best possible outcomes. This article outlines the fundamentals of proper management of pediatric trauma patients.

Management of bleeding following major trauma: a European guideline

INTRODUCTION

Evidence-based recommendations can be made with respect to many aspects of the acute management of the bleeding trauma patient, which when implemented may lead to improved patient outcomes.

METHODS

The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing guidelines for the management of bleeding following severe injury. Recommendations were formulated using a nominal group process and the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) hierarchy of evidence and were based on a systematic review of published literature.

RESULTS

Key recommendations include the following: The time elapsed between injury and operation should be minimised for patients in need of urgent surgical bleeding control, and patients presenting with haemorrhagic shock and an identified source of bleeding should undergo immediate surgical bleeding control unless initial resuscitation measures are successful. A damage control surgical approach is essential in the severely injured patient. Pelvic ring disruptions should be closed and stabilised, followed by appropriate angiographic embolisation or surgical bleeding control, including packing. Patients presenting with haemorrhagic shock and an unidentified source of bleeding should undergo immediate further assessment as appropriate using focused sonography, computed tomography, serum lactate, and/or base deficit measurements. This guideline also reviews appropriate physiological targets and suggested use and dosing of blood products, pharmacological agents, and coagulation factor replacement in the bleeding trauma patient.

CONCLUSION

A multidisciplinary approach to the management of the bleeding trauma patient will help create circumstances in which optimal care can be provided. By their very nature, these guidelines reflect the current state-of-the-art and will need to be updated and revised as important new evidence becomes available.