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Kenyon RM, Leighton JL. Control of Haemorrhage in Orthopaedic Trauma. J Clin Med 2024; 13:4260. [PMID: 39064300 PMCID: PMC11277702 DOI: 10.3390/jcm13144260] [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: 05/28/2024] [Revised: 06/26/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
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.
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McLellan H, Rijnhout TWH, Peterson LM, Stuhlmiller DFE, Edwards J, Jarrouj A, Samanta D, Tager A, Tan ECTH. Prehospital Active and Passive Warming in Trauma Patients. Air Med J 2023; 42:252-258. [PMID: 37356885 DOI: 10.1016/j.amj.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Hypothermia is common among trauma patients and can lead to a serious rise in morbidity and mortality. This study was performed to investigate the effect of active and passive warming measures implemented in the prehospital phase on the body temperature of trauma patients. METHODS In a multicenter, multinational prospective observational design, the effect of active and passive warming measures on the incidence of hypothermia was investigated. Adult trauma patients who were transported by helicopter emergency medical services (HEMS) or ground emergency medical services with an HEMS physician directly from the scene of injury were included. Four HEMS/ground emergency medical services programs from Canada, the United States, and the Netherlands participated. RESULTS A total of 80 patients (n = 20 per site) were included. Eleven percent had hypothermia on presentation, and the initial evaluation occurred predominantly within 60 minutes after injury. In-line fluid warmers and blankets were the most frequently used active and passive warming measures, respectively. Independent risk factors for a negative change in body temperature were transportation by ground ambulance (odds ratio = 3.20; 95% confidence interval, 1.06-11.49; P = .03) and being wet on initial presentation (odds ratio = 3.64; 95% confidence interval, 0.99-13.36; P = .05). CONCLUSION For adult patients transported from the scene of injury to a trauma center, active and passive warming measures, most notably the removal of wet clothing, were associated with a favorable outcome, whereas wet patients and ground ambulance transport were associated with an unfavorable outcome with respect to temperature.
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Affiliation(s)
- Heather McLellan
- Advanced Studies in Critical Care Nursing, Mount Royal University, Mount Royal Gate, Calgary, Alberta, Canada.
| | - Tim W H Rijnhout
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Michael Peterson
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV; HealthNet Aeromedical Services, Charleston, WV
| | | | - Jerry Edwards
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV
| | - Aous Jarrouj
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV
| | - Damayanti Samanta
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV
| | - Alfred Tager
- Charleston Area Medical Center, Institute for Academic Medicine, Charleston, WV
| | - Edward C T H Tan
- Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Dong JF, Zhang F, Zhang J. Detecting traumatic brain injury-induced coagulopathy: What we are testing and what we are not. J Trauma Acute Care Surg 2023; 94:S50-S55. [PMID: 35838367 PMCID: PMC9805481 DOI: 10.1097/ta.0000000000003748] [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] [Indexed: 02/07/2023]
Abstract
ABSTRACT Coagulopathy after traumatic brain injury (TBI) is common and has been closely associated with poor clinical outcomes for the affected patients. Traumatic brain injury-induced coagulopathy (TBI-IC) is consumptive in nature and evolves rapidly from an injury-induced hypercoagulable state. Traumatic brain injury-induced coagulopathy defined by laboratory tests is significantly more frequent than clinical coagulopathy, which often manifests as secondary, recurrent, or delayed intracranial or intracerebral hemorrhage. This disparity between laboratory and clinical coagulopathies has hindered progress in understanding the pathogenesis of TBI-IC and developing more accurate and predictive tests for this severe TBI complication. In this review, we discuss laboratory tests used in clinical and research studies to define TBI-IC, with specific emphasis on what the tests detect and what they do not. We also offer perspective on developing more accurate and predictive tests for this severe TBI complication.
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Affiliation(s)
- Jing-fei Dong
- Bloodworks Research Institute, Seattle, WA, USA
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
| | - Fangyi Zhang
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Jianning Zhang
- Tianjin Institute of Neurology, Tianjin, China
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
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Hetz M, Juratli T, Tiebel O, Giesecke MT, Tsitsilonis S, Held HC, Beyer F, Kleber C. Acquired Factor XIII Deficiency in Patients with Multiple Trauma. Injury 2022; 54:1257-1264. [PMID: 36577625 DOI: 10.1016/j.injury.2022.12.021] [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: 04/09/2022] [Revised: 11/23/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Fibrin stabilizing factor (FXIII) plays a crucial role in blood clotting, tissue repair, and immune defense. FXIII deficiency after trauma can lead to prolonged wound healing due to persistent infections or coagulation disorders. The aim of this study was to describe the prevalence of acquired FXIII deficiency after trauma and to provide a description of the time-course changes of important coagulation parameters in relation to FXIII activity. In this context, patient characteristics, laboratory data, and treatment modalities were examined with respect to their influence on FXIII activity. Furthermore, the effects of in vitro administration of FXIII on clot firmness and outcomes in patients with severe traumatic brain injury were investigated. PATIENTS AND METHODS Two trauma cohorts (A and B) were examined prospectively in a two-center study, and another (cohort C) was examined retrospectively. In cohort A (trauma patients, n=880) routine laboratory tests were conducted, and FXIII activity was measured. In cohort B (polytrauma patients, n=26), additional clinical parameters were collected, and in-vitro FXIII administration and rotational thromboelastometry (ROTEM) analyses were performed. In cohort C (polytrauma patients with severe traumatic brain injury [sTBI], n=84), the impact of initially measured FXIII activity on clinical outcomes after sTBI was investigated using the modified Rankin Scale (mRS) at least 6 months after trauma. RESULTS The prevalence of FXIII activity <70% in cohort A was 12.4%, with significant differences in age, Hb, fibrinogen, and Hct levels, platelet count, aPTT, and INR (vs. prevalence of FXIII activity >70%). Cohort B showed a decrease in FXIII activity from 85% to 58% after 7 days. FXIII deficiency correlated with time after trauma, aPTT, and fibrinogen level, lactate, and Hb levels. In-vitro administration of FXIII showed a positive influence on clot firmness due to improved maximum clot firmness (MCF in FIBTEM) and reduced maximum lysis (ML in EXTEM). Finally, a significant difference in FXIII activity between patients after sTBI with good and poor clinical outcomes was observed 6 months after trauma. CONCLUSION We demonstrated that trauma-associated FXIII deficiency is a common coagulation disorder, with FXIII deficiency increasing further in the first 7 days after trauma, the period of early surgical care. In vitro administration of FXIII was able to demonstrate significant clot stabilizing effects. For trauma patients with sTBI, FXIII activity could serve as a prognostic parameter, as it differed significantly between patients with good and poor clinical outcomes.
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Affiliation(s)
- Michael Hetz
- Department of Operative Medicine (DOPM), Clinic and Polyclinic for Orthopedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig AöR, Liebigstr. 20, 04103 Leipzig, Germany.
| | - Tareq Juratli
- Clinic and Polyclinic for Neurosurgery, University Hospital Carl Gustav Carus of the Technical University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | - Oliver Tiebel
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus of the Technical University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | - Moritz Tobias Giesecke
- Department of Operative Orthopedics and Trauma Surgery, Vivantes Klinikum Spandau, Ringstraße 101B, 12203 Berlin, Germany.
| | - Serafeim Tsitsilonis
- Center for Musculoskeletal Surgery (CMSC), Charité - University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Hanns-Christoph Held
- Clinic and Polyclinic for Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus of the Technical University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | - Franziska Beyer
- UniversityCenter for Orthopedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus of the Technical University of Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
| | - Christian Kleber
- Head of Trauma Surgery, Department of Operative Medicine (DOPM), Clinic and Polyclinic for Orthopedics, Trauma Surgery and Plastic Surgery, University Hospital Leipzig AöR, Germany.
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Dong X, Liu W, Shen Y, Houck K, Yang M, Zhou Y, Zhao Z, Wu X, Blevins T, Koehne AL, Wun TC, Fu X, Li M, Zhang J, Dong JF. Anticoagulation targeting membrane-bound anionic phospholipids improves outcomes of traumatic brain injury in mice. Blood 2021; 138:2714-2726. [PMID: 34610086 PMCID: PMC8703367 DOI: 10.1182/blood.2021011310] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 09/20/2021] [Indexed: 12/25/2022] Open
Abstract
Severe traumatic brain injury (TBI) often causes an acute systemic hypercoagulable state that rapidly develops into consumptive coagulopathy. We have recently demonstrated that TBI-induced coagulopathy (TBI-IC) is initiated and disseminated by brain-derived extracellular vesicles (BDEVs) and propagated by extracellular vesicles (EVs) from endothelial cells and platelets. Here, we present results from a study designed to test the hypothesis that anticoagulation targeting anionic phospholipid-expressing EVs prevents TBI-IC and improves the outcomes of mice subjected to severe TBI. We evaluated the effects of a fusion protein (ANV-6L15) for improving the outcomes of TBI in mouse models combined with in vitro experiments. ANV-6L15 combines the phosphatidylserine (PS)-binding annexin V (ANV) with a peptide anticoagulant modified to preferentially target extrinsic coagulation. We found that ANV-6L15 reduced intracranial hematoma by 70.2%, improved neurological function, and reduced death by 56.8% in mice subjected to fluid percussion injury at 1.9 atm. It protected the TBI mice by preventing vascular leakage, tissue edema, and the TBI-induced hypercoagulable state. We further showed that the extrinsic tenase complex was formed on the surfaces of circulating EVs, with the highest level found on BDEVs. The phospholipidomic analysis detected the highest levels of PS on BDEVs, as compared with EVs from endothelial cells and platelets (79.1, 15.2, and 3.5 nM/mg of protein, respectively). These findings demonstrate that TBI-IC results from a trauma-induced hypercoagulable state and may be treated by anticoagulation targeting on the anionic phospholipid-expressing membrane of EVs from the brain and other cells.
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Affiliation(s)
- Xinlong Dong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Bloodworks Research Institute, Seattle, WA
| | - Wei Liu
- Institute of Pathology, School of Medical Sciences and Gansu Provincial Key Laboratory of Preclinical Study for New Drug Development, Lanzhou University, Lanzhou, China
| | - Yu Shen
- Bloodworks Research Institute, Seattle, WA
| | | | - Mengchen Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuan Zhou
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zilong Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaoping Wu
- Department of Pathology, University of Washington School of Medicine, Seattle, WA
| | - Teri Blevins
- Department of Comparative Medicine, Fred Hutch Cancer Center, Seattle, WA
| | - Amanda L Koehne
- Department of Comparative Medicine, Fred Hutch Cancer Center, Seattle, WA
| | | | - Xiaoyun Fu
- Bloodworks Research Institute, Seattle, WA
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA
| | - Min Li
- Institute of Pathology, School of Medical Sciences and Gansu Provincial Key Laboratory of Preclinical Study for New Drug Development, Lanzhou University, Lanzhou, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, WA
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA
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Tejiram S, Sen S, Romanowski KS, Greenhalgh DG, Palmieri TL. Examining 1:1 vs. 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision. J Burn Care Res 2021; 41:443-449. [PMID: 31912141 DOI: 10.1093/jbcr/iraa001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs. 4:1 packed red blood cell to fresh frozen plasma transfusion strategy during massive burn excision. Children with >20% total body surface area burns were randomized to a 1:1 or 4:1 packed red blood cell/fresh frozen plasma transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, pediatric risk of mortality (PRISM) scores, pediatric logistic organ dysfunction scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n = 34). Mean age, PRISM scores, estimated blood loss (600 ml (400-1175 ml) vs. 600 ml (300-1150 ml), P = 0.68), ventilator days (5 vs. 9, P = 0.47), and length of stay (57 vs. 60 days, P = 0.24) had no difference. No differences in frequency of blood stream infection (20 vs. 18, P = 0.46) or pneumonia events (68 vs. 116, P = 0.08) were noted. On multivariate analysis, only total body surface area burn size, inhalation injury, and PRISM scores (P < 0.05) were significantly associated with infections.
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Affiliation(s)
- Shawn Tejiram
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - Soman Sen
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - Kathleen S Romanowski
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - David G Greenhalgh
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
| | - Tina L Palmieri
- Shriners Hospitals for Children Northern California and the Firefighters Burn Institute Regional Burn Center, Department of Surgery, University of California, Davis, Sacramento, California
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Xu X, Wang C, Wu Y, Houck K, Hilton T, Zhou A, Wu X, Han C, Yang M, Yang W, Shi FD, Stolla M, Cruz MA, Li M, Zhang J, Dong JF. Conformation-dependent blockage of activated VWF improves outcomes of traumatic brain injury in mice. Blood 2021; 137:544-555. [PMID: 33507292 PMCID: PMC7845006 DOI: 10.1182/blood.2020007364] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/27/2020] [Indexed: 12/22/2022] Open
Abstract
Traumatic brain injury-induced coagulopathy (TBI-IC) causes life-threatening secondary intracranial bleeding. Its pathogenesis differs mechanistically from that of coagulopathy arising from extracranial injuries and hemorrhagic shock, but it remains poorly understood. We report results of a study designed to test the hypothesis that von Willebrand factor (VWF) released during acute TBI is intrinsically hyperadhesive because its platelet-binding A1-domain is exposed and contributes to TBI-induced vascular leakage and consumptive coagulopathy. This hyperadhesive VWF can be selectively blocked by a VWF A2-domain protein to prevent TBI-IC and to improve neurological function with a minimal risk of bleeding. We demonstrated that A2 given through intraperitoneal injection or IV infusion reduced TBI-induced death by >50% and significantly improved the neurological function of C57BL/6J male mice subjected to severe lateral fluid percussion injury. A2 protected the endothelium from extracellular vesicle-induced injury, reducing TBI-induced platelet activation and microvesiculation, and preventing a TBI-induced hypercoagulable state. A2 achieved this therapeutic efficacy by specifically blocking the A1 domain exposed on the hyperadhesive VWF released during acute TBI. These results suggest that VWF plays a causal role in the development of TBI-IC and is a therapeutic target for this life-threatening complication of TBI.
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Affiliation(s)
- Xin Xu
- Bloodworks Research Institute, Seattle, WA
- Departments of Neurosurgery, Neurology, and Obstetrics & Gynecology, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chenyu Wang
- Institute of Pathology, School of Medical Sciences, and the Gansu Provincial Key Laboratory of Preclinical Study for New Drug Development, Lanzhou University, Lanzhou, China
| | - Yingang Wu
- Department of Neurosurgery, the First Affiliated Hospital, University of Science and Technology, Hefei, China
| | | | | | | | | | - Cha Han
- Departments of Neurosurgery, Neurology, and Obstetrics & Gynecology, Tianjin Medical University General Hospital, Tianjin, China
| | - Mengchen Yang
- Departments of Neurosurgery, Neurology, and Obstetrics & Gynecology, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Yang
- Bloodworks Research Institute, Seattle, WA
- NanoString Technologies, Seattle, WA
| | - Fu-Dong Shi
- Departments of Neurosurgery, Neurology, and Obstetrics & Gynecology, Tianjin Medical University General Hospital, Tianjin, China
| | | | - Miguel A Cruz
- Cardiovascular Research Section, Department of Medicine, Baylor College of Medicine, Houston, TX
- Center for Translational Research on Inflammatory Diseases, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, TX; and
| | - Min Li
- Institute of Pathology, School of Medical Sciences, and the Gansu Provincial Key Laboratory of Preclinical Study for New Drug Development, Lanzhou University, Lanzhou, China
| | - Jianning Zhang
- Departments of Neurosurgery, Neurology, and Obstetrics & Gynecology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Seattle, WA
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA
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Chang T, Yan X, Zhao C, Zhang Y, Wang B, Gao L. Risk Factors and Neurologic Outcomes in Patients with Traumatic Brain Injury and Coagulopathy Within 72 h After Surgery. Neuropsychiatr Dis Treat 2021; 17:2905-2913. [PMID: 34531657 PMCID: PMC8439966 DOI: 10.2147/ndt.s323897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/06/2021] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The purpose of this study was to explore the effect of coagulopathy in patients with traumatic brain injury (TBI) during the early postoperative period. METHODS The baseline characteristics, intraoperative management, and follow-up data of 462 patients with TBI between January 2015 and June 2019 were collected and retrospectively analyzed by multivariate logistic regression. Coagulopathy was defined as activated partial thromboplastin time > 40 s, international normalized ratio > 1.4, or platelet counts < 100×109/L. RESULTS Multivariate logistic regression analysis revealed that the Glasgow Coma Scale (GCS) on admission, Injury Severity Score (ISS) on admission, pupil mydriasis, duration of surgery, intraoperative blood loss, and intraoperative crystalloid resuscitation were independent risk factors for patients who developed coagulopathy after surgery. There were statistical differences in mortality (p = 0.049), the Glasgow Outcome Scale-Extended (GCS-E; p = 0.024), and the modified Rankin Scale (p = 0.043) between the patients with and without coagulopathy 1 week after surgery. Coagulopathy within 72 h after surgery revealed the higher mortality at 1 week (66.7%), 3 months (71.4%), and 6 months (76.2%). Coagulopathy within 72 h after surgery in patients with a TBI predicted worse disease progression and unfavorable neurologic outcomes. CONCLUSION Taking practical and reasonable measures to manage these risk factors may protect patients with TBI from postoperative coagulopathy.
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Affiliation(s)
- Tao Chang
- Department of Emergency, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Xigang Yan
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Chao Zhao
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Yufu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Bao Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
| | - Li Gao
- Department of Neurosurgery, The Second Affiliated Hospital of Air Force Medical University, Xi'an, 710038, Shaanxi Province, People's Republic of China
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Xu X, Kozar R, Zhang J, Dong JF. Diverse activities of von Willebrand factor in traumatic brain injury and associated coagulopathy. J Thromb Haemost 2020; 18:3154-3162. [PMID: 32931638 PMCID: PMC7855263 DOI: 10.1111/jth.15096] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/20/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability. Patients with isolated TBI lose a limited amount of blood to primary injury, but they often develop secondary coagulopathy, resulting in delayed or recurrent intracranial and intracerebral hematoma. TBI-induced coagulopathy is closely associated with poor outcomes for these patients, including death. This secondary coagulopathy is consumptive in nature, involving not only brain-derived molecules, coagulation factors, and platelets, but also endothelial cells in a complex process now called blood failture. A key question is how a localized injury to the brain is rapidly disseminated to affect systemic hemostasis that is not directly affected the way it is in trauma to the body and limbs, especially with hemorrhagic shock. Increasing evidence suggests that the adhesive ligand von Willebrand factor (VWF), which is synthesized in and released from endothelial cells, plays a paradoxical role in both facilitating local hemostasis at the site of injury and also propagating TBI-induced endotheliopathy and coagulopathy systemically. This review discusses recent progress in understanding these diverse activities of VWF and the knowledge gaps in defining their roles in TBI and associated coagulopathy.
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Affiliation(s)
- Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Rosemary Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, US
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Institute of Neurology, Tianjin, China
| | - Jing-fei Dong
- Bloodworks Research Institute, Seattle, WA, US
- Hematology Division, Department of Medicine, University of Washington School of Medicine, Seattle, WA, US
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10
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Ghaffarpasand F, Abbasi HR, Bolandparvaz S, Paydar S, Dehghankhalili M. Tranexamic Acid; A Glittering Player in the Field of Trauma. Bull Emerg Trauma 2020; 8:53-55. [PMID: 32420388 PMCID: PMC7211392 DOI: 10.30476/beat.2020.46443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Fariborz Ghaffarpasand
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran.,Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Abbasi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Shahram Paydar
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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11
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Leighton JL, You D, Schneider P. Limiting Blood Loss in Orthopaedic Trauma: Strategies and Effects. Injury 2020; 51 Suppl 2:S123-S127. [PMID: 32467044 DOI: 10.1016/j.injury.2020.04.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 02/02/2023]
Abstract
Trauma is a major cause of mortality globally, with post-traumatic hemorrhage being the leading cause of death amongst trauma patients. In this paper, the authors review the underlying pathophysiology of trauma-related hemorrhagic shock, specifically the factors which contribute to the development of the acute coagulopathy of trauma shock (ACoTS). We then review the best available evidence for treatment strategies in the pre-hospital setting, as well as the in-hospital setting. Interventions that are strongly supported in the literature include utilization of a well-organized trauma system with direct transport to a designated trauma centre, the early use of tranexamic acid, and damage control orthopaedic surgical techniques and resuscitation protocols. Targeted resuscitation is an evolving field, with use of thromboelastography to guide resuscitation being a particularly promising area. Special trauma populations at particularly high risk are also reviewed, including the geriatric population, as well as unstable pelvic fractures, which are each at increased risk for poor outcomes, and deserve special attention. Major advances have been made in this important area, and ongoing research into the understanding and correction of ACoTS will continue to guide practice.
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Affiliation(s)
| | - Daniel You
- University of Calgary, Calgary, AB, Canada
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12
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Bocci MG, Nardi G, Veronesi G, Rondinelli MB, Palma A, Fiore V, De Candia E, Bianchi M, Maresca M, Barelli R, Tersali A, Dell'Anna AM, De Pascale G, Cutuli SL, Mercurio G, Caricato A, Grieco DL, Antonelli M, Cingolani E. Early coagulation support protocol: A valid approach in real-life management of major trauma patients. Results from two Italian centres. Injury 2019; 50:1671-1677. [PMID: 31690405 DOI: 10.1016/j.injury.2019.09.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Early coagulation support (ECS) includes prompt infusion of tranexamic acid, fibrinogen concentrate, and packed red blood cells for initial resuscitation of major trauma patients. The aim of this study was to determine the effects, in terms of blood product consumption, length of stay, and in-hospital mortality, of the ECS protocol, compared to the massive transfusion protocol (MTP) in the treatment of major trauma patients. PATIENTS AND METHODS A retrospective analysis was conducted using the registry data of two Italian trauma centres. Adult major trauma patients with, or at risk of, active bleeding who were managed according to the MTP during the years 2011-2012, or the ECS protocol during the years 2013-2014 and were considered at risk of multiple transfusions, were enrolled. The primary endpoint was to determine whether the ECS protocol reduces the use of blood products in the acute management of trauma patients. Secondary endpoints were the outcome measures of length of stay in ICU, length of stay in hospital, and mortality at 24-hours and 28-days after hospital admission. RESULTS Among the 518 major trauma patients admitted to the trauma centres during the study period, 235 patients (118 in the pre-ECS period and 117 in the ECS period) matched one of the inclusion criteria and were enrolled in the study. Compared with the pre-ECS period, the ECS period showed a reduction in the average consumption of packed red blood cells (-1.87 units, 95% confidence interval [CI], -2.40, -1.34), platelets (-1.28 units; 95% CI, -1.64, -0.91), and fresh frozen plasma (-1.69; 95% CI, -2.14, -1.25) in the first 24-hours. Furthermore, during the ECS period, we recorded a 10-day reduction in the hospital length of stay (-10 days, 95% CI, -11.6, -8.4) and a non-significant 28-day mortality increase. CONCLUSIONS The ECS protocol was effective in reducing blood product consumption compared to the MTP and confirmed the importance of early fibrinogen administration as a strategy of rapid coagulation. This novel approach may be adopted in real-life management of major trauma patients.
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Affiliation(s)
- Maria Grazia Bocci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy.
| | - Giuseppe Nardi
- UOC Anestesia e Rianimazione, Ospedale Infermi, Rimini, Italy
| | - Giovanni Veronesi
- Centro Ricerche in Epidemiologia e Medicina Preventiva, Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi dell'Insubria, Varese, Italy
| | - Maria Beatrice Rondinelli
- UOC Medicina Trasfusionale e Cellule Staminali, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Antonella Palma
- UOC Anestesia e Rianimazione, CTO Azienda Ospedaliera dei Colli, Napoli, Italy
| | - Valentina Fiore
- UOC Anestesia e Rianimazione, Azienda Ospedaliera Vito Fazi, Lecce, Italy
| | - Erica De Candia
- UOS Malattie Emorragiche e Trombotiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Medicina Interna e Geriatria, Università Cattolica del sacro Cuore, Rome, Italy
| | - Maria Bianchi
- UOC Emotrasfusione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Ematologia, Università Cattolica del sacro Cuore, Rome, Italy
| | - Maddalena Maresca
- UOC Emotrasfusione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Ematologia, Università Cattolica del sacro Cuore, Rome, Italy
| | - Roberta Barelli
- UOC Anestesia e Rianimazione, Ospedale San Giovanni Calibita Fatebenefratelli, Rome, Italy
| | - Alessandra Tersali
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Antonio Maria Dell'Anna
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Gennaro De Pascale
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Giovanna Mercurio
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Anselmo Caricato
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Domenico Luca Grieco
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del sacro Cuore, Rome, Italy
| | - Emiliano Cingolani
- UOSD Shock e Trauma, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
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Ogawa F, Sakai T, Takahashi K, Kato M, Yamaguchi K, Okazaki S, Abe T, Iwashita M, Takeuchi I. A case report: Veno-venous extracorporeal membrane oxygenation for severe blunt thoracic trauma. J Cardiothorac Surg 2019; 14:88. [PMID: 31060587 PMCID: PMC6501329 DOI: 10.1186/s13019-019-0908-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/22/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in trauma patients has been controversial, but VV-ECMO plays a crucial role when the lungs are extensively damaged and when conventional management has failed. VV-ECMO provides adequate tissue oxygenation and an opportunity for lung recovery. However, VV-ECMO remains contraindicated in patients with a risk of bleeding because of systemic anticoagulation during the treatment. The most important point is controlling the bleeding from severe trauma. Case A 32-year-old male experienced blunt trauma due to a traffic accident. He presented with bilateral hemopneumothorax and bilateral flail chest. We performed emergency thoracotomy for active bleeding and established circulatory stability. After surgery, the oxygenation deteriorated under mechanical ventilation, so we decided to establish VV-ECMO. However, bleeding from the bilateral lung contusions increased after VV-ECMO was established, and the patient was switched to heparin-free ECMO. After conversion, we could control the bronchial bleeding, especially the lung hematomas, and the oxygenation recovered. The patient was discharged without significant complications. VV-ECMO and mechanical ventilation were stopped on days 10 and 11, respectively. He was discharged from the ICU on day 15. Conclusion When we consider the use of ECMO for patients with uncontrollable, severe bleeding caused by blunt trauma, it may be necessary to use a higher flow setting for heparin-free ECMO than typically used for patients without trauma to prevent thrombosis.
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Affiliation(s)
- Fumihiro Ogawa
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan. .,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan.
| | - Takuma Sakai
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan.,Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, 232-0024, Japan
| | - Ko Takahashi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Makoto Kato
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Keishi Yamaguchi
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Sayo Okazaki
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Takeru Abe
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Masayuki Iwashita
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan.,Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, 232-0024, Japan
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Crewdson K, Lockey D, Voelckel W, Temesvari P, Lossius HM. Best practice advice on pre-hospital emergency anaesthesia & advanced airway management. Scand J Trauma Resusc Emerg Med 2019; 27:6. [PMID: 30665441 PMCID: PMC6341545 DOI: 10.1186/s13049-018-0554-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/25/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Effective and timely airway management is a priority for sick and injured patients. The benefit and conduct of pre-hospital emergency anaesthesia (PHEA) and advanced airway management remains controversial but there are a proportion of critically ill and injured patients who require urgent advanced airway management prior to hospital arrival. This document provides current best practice advice for the provision of PHEA and advanced airway management. METHOD This best practice advice was developed from EHAC Medical Working Group enforced by pre-hospital critical care experts. The group used a nominal group technique to establish the current best practice for the provision of PHEA and advanced airway management. The group met on three separate occasions to discuss and develop the guideline. All members of the working party were able to access and edit the guideline online. RESULTS This EHAC best practice advice covers all areas of PHEA and advanced airway management and provides up to date evidence of current best practice. CONCLUSION PHEA and advanced airway management are complex interventions that should be delivered by appropriately trained personnel using a well-rehearsed approach and standardised equipment. Where advanced airway interventions cannot be delivered, careful attention should be given to applying basic airway interventions and ensuring their effectiveness at all times.
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Affiliation(s)
| | - David Lockey
- Norwegian Air Ambulance Foundation, Drøbak, Norway
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15
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Tang Z, Huang Q, Zhang J, Yang R, Wei W, Liu H. Fourteen-Day Mortality in Pediatric Patients with Traumatic Brain Injury After Early Decompressive Craniectomy: A Single-Center Retrospective Study. World Neurosurg 2018; 119:e389-e394. [PMID: 30071325 DOI: 10.1016/j.wneu.2018.07.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze the risk factors for 14-day mortality in pediatric patients undergoing early decompressive craniectomy (DC) after traumatic brain injury (TBI). METHODS This retrospective analysis included all pediatric patients (≤16 years of age) undergoing DC within 12 hours of TBI between August 2011 and July 2017 at the authors' institute. Demographic information, clinical characteristics, surgical information, and laboratory parameters were retrieved from medical records. Risk factors for 14-day mortality were analyzed using multivariate logistic regression models. First, potentially relevant variables were compared between those who died within 14 days versus those who did not. Variables with P < 0.10 were entered into the final multivariate regression analysis. RESULTS A total of 36 patients (23 boys and 13 girls; median age, 7 years) were included in the analysis. Fall (n = 19, 52.8%) was the leading cause of injury. The 14-day mortality was 38.9% (14/36). At the time of admission, the median Glasgow Score Scale (GCS) was 6 (IQR 4-8), and the mean Injury Severity Score (ISS) (± standard deviation) was 29.03 ± 8.54. Preoperative hypoxia, defined as oxyhemoglobin arterial saturation <90% or apnea >20 seconds, was observed in 6 patients (16.7%). Coagulopathy was present in 14 patients (38.9%). Multivariate logistic regression analysis suggested an association between 14-day mortality and younger age (odds ratio [OR] = 0.708, 95% confidence interval [CI]: 0.513-0.978; P = 0.036) and higher ISS (OR = 1.399; 95% CI: 1.023-1.914; P = 0.035). CONCLUSIONS In children undergoing early DC after TBI, risk factors for 14-day mortality include younger age and higher ISS.
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Affiliation(s)
- Zhiji Tang
- Department of Neurosurgery, the Affiliated Brain Hospital, Nanjing Medical University, Nanjing, People's Republic of China; Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Qianliang Huang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Jinshi Zhang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Ruijin Yang
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Wenjin Wei
- Department of Neurosurgery, Ganzhou People's Hospital, Ganzhou, People's Republic of China
| | - Hongyi Liu
- Department of Neurosurgery, the Affiliated Brain Hospital, Nanjing Medical University, Nanjing, People's Republic of China.
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16
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Gando S, Mayumi T, Ukai T. Activated protein C plays no major roles in the inhibition of coagulation or increased fibrinolysis in acute coagulopathy of trauma-shock: a systematic review. Thromb J 2018; 16:13. [PMID: 29946227 PMCID: PMC6006835 DOI: 10.1186/s12959-018-0167-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/15/2018] [Indexed: 12/27/2022] Open
Abstract
Background The pathophysiological mechanisms of acute coagulopathy of trauma-shock (ACOTS) are reported to include activated protein C-mediated suppression of thrombin generation via the proteolytic inactivation of activated Factor V (FVa) and FVIIIa; an increased fibrinolysis via neutralization of plasminogen activator inhibitor-1 (PAI-1) by activated protein C. The aims of this study are to review the evidences for the role of activated protein C in thrombin generation and fibrinolysis and to validate the diagnosis of ACOTS based on the activated protein C dynamics. Methods We conducted systematic literature search (2007–2017) using PubMed, the Cochrane Database of Systematic Reviews (CDSR), and the Cochrane Central Register of Controlled Trials (CENTRAL). Clinical studies on trauma that measured activated protein C or the circulating levels of activated protein C-related coagulation and fibrinolysis markers were included in our study. Results Out of 7613 studies, 17 clinical studies met the inclusion criteria. The levels of activated protein C in ACOTS were inconsistently decreased, showed no change, or were increased in comparison to the control groups. Irrespective of the activated protein C levels, thrombin generation was always preserved or highly elevated. There was no report on the activated protein C-mediated neutralization of PAI-1 with increased fibrinolysis. No included studies used unified diagnostic criteria to diagnose ACOTS and those studies also used different terms to refer to the condition known as ACOTS. Conclusions None of the studies showed direct cause and effect relationships between activated protein C and the suppression of coagulation and increased fibrinolysis. No definitive diagnostic criteria or unified terminology have been established for ACOTS based on the activated protein C dynamics. Electronic supplementary material The online version of this article (10.1186/s12959-018-0167-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Satoshi Gando
- 1Division of Acute and Critical Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, N15W7, Kita-ku, Sapporo, 060-8638 Japan
| | - Toshihiko Mayumi
- 2Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Tomohiko Ukai
- 3Department of Social Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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Petrosoniak A, Hicks C. Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock. Emerg Med Clin North Am 2017; 36:41-60. [PMID: 29132581 DOI: 10.1016/j.emc.2017.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Trauma resuscitation is a complex and dynamic process that requires a high-performing team to optimize patient outcomes. More than 30 years ago, Advanced Trauma Life Support was developed to formalize and standardize trauma care; however, the sequential nature of the algorithm that is used can lead to ineffective prioritization. An improved understanding of shock mandates an updated approach to trauma resuscitation. This article proposes a resequenced approach that (1) addresses immediate threats to life and (2) targets strategies for the diagnosis and management of shock causes. This updated approach emphasizes evidence-based resuscitation principles that align with physiologic priorities.
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Affiliation(s)
- Andrew Petrosoniak
- Department of Emergency Medicine, St. Michael's Hospital, 1-008c Shuter Wing, 30 Bond street, Toronto, Ontario M5B 1W8, Canada.
| | - Christopher Hicks
- Department of Emergency Medicine, St. Michael's Hospital, 1-008c Shuter Wing, 30 Bond street, Toronto, Ontario M5B 1W8, Canada
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18
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Acute traumatic coagulopathy in a critically injured pediatric population: Definition, trend over time, and outcomes. J Trauma Acute Care Surg 2017; 81:34-41. [PMID: 26886002 DOI: 10.1097/ta.0000000000001002] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND While our understanding of acute traumatic coagulopathy (ATC) in adults is advancing, the pediatric literature on ATC is limited. Children have a unique injury profile and physiologic response to trauma; however, the impact of this phenomenon on ATC has not been fully elucidated. METHODS We performed a retrospective review of our trauma registry from 2005 to 2014. Level 1 trauma patients age 0 year to 17 years requiring admission to the intensive care unit were included. Variables included admission vital signs and laboratory studies, product transfusion, injuries, and mortality. Youden index was used to determine optimum cutoff point for admission international normalized ratio (INR) as a predictor of mortality. Logistic regression modeling was used to determine independent predictors of mortality adjusting for hypotension, hypothermia, acidosis, injury severity, hemorrhage, and head injury. χ tests were performed evaluating for association between mortality and 24-hour INR as well as between transfusion and INR correction. RESULTS A total of 776 patients were analyzed: 29.2% (n = 227) had an admission INR of 1.3 or greater, and 13.3% (n = 103) had an admission INR of 1.5 or greater. Youden index demonstrated optimum cutoff at INR of 1.3 or greater to distinguish survivors and nonsurvivors. Overall mortality rate was 11.1% (n = 86). Elevated INR was independently associated with mortality (odds ratio, 3.77; p < 0.001) after controlling for other predictors in regression modeling. Death was also associated with elevated INR at 24 hours and worsening INR trend over time. Patients who received plasma were equally likely to normalize their INR compared with those who were not transfused (p = nonsignificant). Findings were consistent across age groups. CONCLUSION INR likely serves as a marker of systemic dysregulation rather than a treatment target in ATC. Elevated admission INR, elevated INR at 24 hours, and overall trend in INR strongly predict mortality in a diverse pediatric trauma population; however, product transfusion did not influence the INR trend or clinical outcome. Further research is warranted to evaluate potential upstream mediators of ATC and targets for intervention in pediatric trauma patients. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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19
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Abstract
Following results from the CRASH-2 trial, tranexamic acid (TXA) gained considerable interest for the treatment of hemorrhage in trauma patients. Although TXA is effective at reducing mortality in patients presenting within 3 hours of injury, optimal dosing, timing of administration, mechanism, and pharmacokinetics require further elucidation. The concept of fibrinolysis shutdown in hemorrhagic trauma patients has prompted discussion of real-time viscoelastic testing and its potential role for appropriate patient selection. The results of ongoing clinical trials will help establish high-quality evidence for optimal incorporation of TXA in mature trauma networks in the United States and abroad.
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Affiliation(s)
- Ricardo J Ramirez
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Philip C Spinella
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Grant V Bochicchio
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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20
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Extracorporeal life support is safe in trauma patients. Injury 2017; 48:121-126. [PMID: 27866648 DOI: 10.1016/j.injury.2016.11.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 10/30/2016] [Accepted: 11/10/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The role of extracorporeal life support (ECLS) in the critically ill trauma patient is poorly defined, possibly leading to the underutilization of this lifesaving therapy in this population. This study examined survival rates and risk factors for death in trauma patients who received ECLS. METHODS Data from the National Trauma Data Bank was retrospectively reviewed to identify trauma patients who received ECLS from January 2012 to December 2014. Clinical outcomes and risk factors for death were examined in these patients. RESULTS Eighty patients were identified and included in the final analysis. Overall survival to hospital discharge was 64%. Survivors and non-survivors were similar in regard to age, gender, weight, and injury mechanism. Non-survivors had greater median injury severity scores (ISS) (29 non-survivors vs. 24 survivors, p=0.018) and had a shorter median total hospital length of stay (8days non-survivors vs. 32days survivors, p<0.001). Analysis of specific anatomic locations of traumatic injury, including serious head/neck, thoracic, and abdominal injuries, revealed no impact on patient survival. Multivariable logistic regression analysis identified increasing age and ISS as significant risk factors for mortality; whereas treatment at facilities that performed multiple ECLS runs over the study period was associated with improved survival. CONCLUSIONS Extracorporeal life support appears to be an effective treatment option in trauma patients with severe cardiopulmonary failure. Survival in trauma patients receiving ECLS is similar to that observed in the general ECLS population and this may represent an underutilized therapy in this population.
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Wu R, Peng LG, Zhao HM. Diverse coagulopathies in a rabbit model with different abdominal injuries. World J Emerg Med 2017; 8:141-147. [PMID: 28458760 DOI: 10.5847/wjem.j.1920-8642.2017.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Although coagulopathy can be very common in severe traumatic shock patients, the exact incidence and mechanism remain unclear. In this study, a traumatic shock rabbit model with special abdomen injuries was developed and evaluated by examining indicators of clotting and fibrinolysis. METHODS Forty New Zealand white rabbits were randomly divided into four groups: group 1 (sham), group 2 (hemorrhage), group 3 (hemorrhage-liver injury), and group 4 (hemorrhage-liver injury/intestinal injury-peritonitis). Coagulation was detected by thromboelastography before trauma (T0), at 1 hour (T1) and 4 hours (T2) after trauma. RESULTS Rabbits that suffered from hemorrhage alone did not differ in coagulation capacity compared with the sham group. The clot initiations (R times) of group 3 at T1 and T2 were both shorter than those of groups 1, 2, and 4 (P<0.05). In group 4, clot strength was decreased at T1 and T2 compared with those in groups 1, 2, and 3 (P<0.05), whereas the R time and clot polymerization were increased at T2 (P<0.05). The clotting angle significantly decreased in group 4 compared with groups 2 and 3 at T2 (P<0.05). CONCLUSION This study suggests that different abdominal traumatic shock show diverse coagulopathy in the early phase. Isolated hemorrhagic shock shows no obvious effect on coagulation. In contrast, blunt hepatic injury with hemorrhage shows hypercoagulability, whereas blunt hepatic injury with hemorrhage coupled with peritonitis caused by a ruptured intestine shows a tendency toward hypocoagulability.
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Affiliation(s)
- Ruo Wu
- Department of Emergency Medicine, Haikou People's Hospital Affiliated to Central South University, Haikou 570208, China
| | - Luo-Gen Peng
- Department of Emergency Medicine, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Hui-Min Zhao
- Department of Emergency Medicine, the First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
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Sprengel K, Simmen H, Werner CML, Sulser S, Plecko M, Keller C, Mica L. Resuscitation with polymeric plasma substitutes is permissive for systemic inflammatory response syndrome and sepsis in multiply injured patients: a retrospective cohort study. Eur J Med Res 2016; 21:39. [PMID: 27737718 PMCID: PMC5064963 DOI: 10.1186/s40001-016-0227-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 08/10/2016] [Indexed: 12/24/2022] Open
Abstract
Objective Multiple trauma is often accompanied by systemic inflammatory response syndrome (SIRS). The aim of this study was to investigate the impact of polymeric plasma substitutes on the development of SIRS or sepsis. Methods We included 2969 patients aged ≥16 years with an Injury Severity Score (ISS) >16 in this study. The sample was subdivided into three groups: patients who did not receive colloids and those who received <5L colloids and >5L colloids within the first 48 h. Data were analyzed using IBM SPSS® for Windows version 22.0; analysis of variance was used for continuous normally distributed data and Kruskal–Wallis test for categorical data. The predictive quality of colloid treatment was analyzed using the receiver operating characteristic (ROC) curves. Independent predictively was analyzed by binary logistic regression. Data were considered significant if P < 0.05. Data are presented as the mean ± standard deviation. Results The SIRS score increased with the amount of colloid used (1.9 ± 1.4 vs. 2.4 ± 1.2 vs. 3.2 ± 0.9; P < 0.001). However, the predictive quality was low, with an area under the ROC of 0.693 for SIRS and 0.669 for sepsis (P < 0.001). Binary logistic regression revealed colloids as an independent factor for the development of SIRS and sepsis (odds ratios: SIRS 3.325 and sepsis 8.984; P < 0.001). Conclusion Besides other factors, colloids have a significant permissive effect and are independent predictors for the development of SIRS and sepsis in multiply injured patients. Trial registration ‘Retrospektive Analysen in der Chirurgischen Intensivmedizin’ No. St. V. 01-2008
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Affiliation(s)
- Kai Sprengel
- Division of Trauma Surgery, University Hospital of Zürich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Hanspeter Simmen
- Division of Trauma Surgery, University Hospital of Zürich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Clément M L Werner
- Division of Trauma Surgery, University Hospital of Zürich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Simon Sulser
- Institute of Anesthesiology, University Hospital of Zürich, 8091, Zurich, Switzerland
| | - Michael Plecko
- Division of Trauma Surgery, University Hospital of Zürich, Rämistrasse 100, 8091, Zurich, Switzerland
| | | | - Ladislav Mica
- Division of Trauma Surgery, University Hospital of Zürich, Rämistrasse 100, 8091, Zurich, Switzerland.
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Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma. J Trauma Acute Care Surg 2016; 80:711-6. [DOI: 10.1097/ta.0000000000000954] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mica L, Simmen H, Werner CML, Plecko M, Keller C, Wirth SH, Sprengel K. Fresh frozen plasma is permissive for systemic inflammatory response syndrome, infection, and sepsis in multiple-injured patients. Am J Emerg Med 2016; 34:1480-5. [PMID: 27260556 DOI: 10.1016/j.ajem.2016.04.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The correction of coagulopathy with fresh frozen plasma (FFP) is one of the main issues in the treatment of multiple-injured patients. Infectious and septic complications contribute to an adverse outcome in multiple-injured patients. Here, we investigated the role of FFP in the development of inflammatory complications given within the first 48 hours. METHODS A total of 2033 patients with multiple injuries and an Injury Severity Score greater than 16 points and aged 16 years or older were included. The population was subdivided into 2 groups: those who received FFP and those who did not. The data were analyzed using SPSS version 22.0. Associations between the data were tested using Pearson correlation. Independent predictivity was analyzed by binary logistic regression and multivariate regression. Data were considered as significant if P<.05. RESULTS The prothrombin time at admission was significantly lower (68.5%±23.3% vs 81.8%±21.0% normal; P<.001) in the group receiving FFP. The application of FFP led to a more severe systemic inflammatory response syndrome (SIRS) grade (3.0±1.2 vs 2.2±1.4; P<.001), to a higher infection rate (48% vs 28%; P<.001), and to a higher sepsis rate (29% vs 13%; P<.001) in the patients receiving FFP. The correlations between SIRS and the incidence of infections and sepsis increased with the amount of FFP applied (P<.001). CONCLUSIONS Treatment with FFP of bleeding patients with multiple injuries enhances the risk of SIRS, infection, and sepsis; however, a multifactorial genesis has to be postulated.
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Affiliation(s)
- Ladislav Mica
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland.
| | - Hanspeter Simmen
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | - Clément M L Werner
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | - Michael Plecko
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
| | | | | | - Kai Sprengel
- Division of Trauma Surgery, University Hospital of Zürich, 8091 Zürich, Switzerland
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Callum JL, Nascimento B, Alam A. Massive haemorrhage protocol: what's the best protocol? ACTA ACUST UNITED AC 2016. [DOI: 10.1111/voxs.12181] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- J. L. Callum
- Department of Clinical Pathology; Sunnybrook Health Sciences Centre; University of Toronto; Toronto ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
| | - B. Nascimento
- Department of Surgery; Sunnybrook Health Sciences Centre; University of Toronto; Toronto ON Canada
| | - A. Alam
- Department of Anesthesia; Sunnybrook Health Sciences Centre; University of Toronto; Toronto ON Canada
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Abstract
BACKGROUND The presence of coagulopathy is common after severe trauma. The aim of this study was to identify whether isolated severe traumatic brain injury (TBI) is an independent risk factor for coagulopathy. METHODS Prospective observational cohort of adult patients admitted to a Level I Trauma Center within 6 h of injury. Patients were categorized according to the abbreviated injury scale (AIS): Group 1-isolated severe TBI (AIS head ≥ 3 + AIS non-head < 3); Group 2-severe multisystem trauma associated with severe TBI (AIS head ≥ 3 + AIS non-head ≥ 3); Group 3-severe multisystem trauma without TBI (AIS head < 3 + AIS non-head ≥ 3). Primary outcome was the development of coagulopathy. Secondary outcome was in-hospital mortality. RESULTS Three hundred and forty five patients were included (Group 1 = 48 patients, Group 2 = 137, and Group 3 = 160). Group 1 patients had the lowest incidence of coagulopathy and disseminated intravascular coagulopathy, and in general presented with better coagulation profile measured by either classic coagulation tests, thromboelastography or clotting factors. Isolated severe TBI was not an independent risk factor for the development of coagulopathy (OR 1.06; 0.35-3.22 CI, p = 0.92), however, isolated severe TBI patients who developed coagulopathy had higher mortality rates than isolated severe TBI patients without coagulopathy (66 vs. 16.6 %, p < 0.05). The presence of coagulopathy (OR 5.61; 2.65-11.86 CI, p < 0.0001) and isolated severe TBI (OR 11.51; 3.9-34.2 CI, p < 0.0001) were independent risk factors for in-hospital mortality. CONCLUSION Isolated severe TBI is not an independent risk factor for the development of coagulopathy. However, severe TBI patients who develop coagulopathy have extremely high mortality rates.
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Lynch AM, O'Toole TE, Respess M. Transfusion practices for treatment of dogs hospitalized following trauma: 125 cases (2008–2013). J Am Vet Med Assoc 2015; 247:643-9. [DOI: 10.2460/javma.247.6.643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Chay J, Koh M, Tan HH, Ng J, Ng HJ, Chia N, Kuperan P, Tan J, Lew E, Tan LK, Koh PL, Desouza KA, Bin Mohd Fathil S, Kyaw PM, Ang AL. A national common massive transfusion protocol (MTP) is a feasible and advantageous option for centralized blood services and hospitals. Vox Sang 2015; 110:36-50. [PMID: 26178308 DOI: 10.1111/vox.12311] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 05/29/2015] [Accepted: 06/08/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND A common national MTP was jointly implemented in 2011 by the national blood service (Blood Services Group) and seven participating acute hospitals to provide rapid access to transfusion support for massively haemorrhaging patients treated in all acute care hospitals. METHODS Through a systematic clinical workflow, blood components are transfused in a ratio of 1:1:1 (pRBC: whole blood-derived platelets: FFP), together with cryoprecipitate for fibrinogen replacement. The composition of components for the MTP is fixed, although operational aspects of the MTP can be adapted by individual hospitals to suit local hospital workflow. The MTP could be activated in support of any patient with critical bleeding and at risk of massive transfusion, including trauma and non-trauma general medical, surgical and obstetric patients. RESULTS There were 434 activations of the MTP from October 2011 to October 2013. Thirty-nine per cent were for trauma patients, and 30% were for surgical patients with heavy intra-operative bleeding, with 25% and 6% for patients with gastrointestinal bleeding and peri-partum haemorrhage, respectively. Several hospitals reported reduction in mean time between request and arrival of blood. Mean transfusion ratio achieved was one red cell unit: 0·8 FFP units: 0·8 whole blood-derived platelet units: 0·4 units of cryoprecipitate. Although cryoprecipitate usage more than doubled after introduction of MTP, there was no significant rise in overall red cells, platelet and FFP usage following implementation. CONCLUSION This successful collaboration shows that shared transfusion protocols are feasible and potentially advantageous for hospitals sharing a central blood provider.
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Affiliation(s)
- J Chay
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - M Koh
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - H H Tan
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - J Ng
- Department of Surgery, Singapore General Hospital, Singapore City, Singapore
| | - H J Ng
- Department of Haematology, Singapore General Hospital, Singapore City, Singapore
| | - N Chia
- Department of Anaesthesiology, Khoo Teck Puat Hospital, Singapore City, Singapore
| | - P Kuperan
- Department of Haematology, Tan Tock Seng Hospital, Singapore City, Singapore
| | - J Tan
- Department of Anaesthesiology, Tan Tock Seng Hospital, Singapore City, Singapore
| | - E Lew
- Department of Anaesthesiology, KK Woman's & Children's Hospital, Singapore City, Singapore
| | - L K Tan
- Department of Haematology, National University Hospital, Singapore City, Singapore
| | - P L Koh
- Paediatrics, National University Hospital, Singapore City, Singapore
| | - K A Desouza
- Department of Anaesthesiology, Changi General Hospital, Singapore City, Singapore
| | - S Bin Mohd Fathil
- Department of Anaethesiology, Jurong Health Services, Singapore City, Singapore
| | - P M Kyaw
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
| | - A L Ang
- Blood Services Group, Health Sciences Authority, Singapore City, Singapore
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Buehner M, Edwards MJ. Massive Transfusion Protocols in the Pediatric Trauma Patient: An Update. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0092-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
PURPOSE OF REVIEW This review article explores the recent literature regarding the optimal type and amount of intravenous fluids for the trauma patient from the time of injury through their ICU stay. It discusses damage control principles as well as targeted resuscitation utilizing new technology. RECENT FINDINGS In the prehospital arena, intravenous fluids have been associated with worse patient outcomes due to increased coagulopathy and time to definitive care. Once in the trauma bay, damage control resuscitation principles apply to the severely injured patient. Large volume crystalloid infusion increases mortality. The best patient outcomes have been found with transfusion of blood products in a ratio that closely mimics whole blood. Thrombelastography is a useful adjunct in resuscitation and can help guide the judicious use of blood products. New technology can help providers ascertain when a patient is appropriately resuscitated by determining adequate global and regional perfusion. SUMMARY During the resuscitation of the acutely injured patient, crystalloids should be limited in favor of blood components. Damage control principles apply until definitive hemostasis is obtained, at which point the focus should change to targeted resuscitation using traditional global endpoints of resuscitation in conjunction with determinants of regional perfusion.
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Carreras-Gonzalez E, Brió-Sanagustin S. Prevención de complicaciones en el transporte interhospitalario aéreo del paciente crítico pediátrico. An Pediatr (Barc) 2014; 81:205-11. [DOI: 10.1016/j.anpedi.2013.11.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 11/04/2013] [Accepted: 11/26/2013] [Indexed: 12/01/2022] Open
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LUNDE J, STENSBALLE J, WIKKELSØ A, JOHANSEN M, AFSHARI A. Fibrinogen concentrate for bleeding--a systematic review. Acta Anaesthesiol Scand 2014; 58:1061-74. [PMID: 25059813 DOI: 10.1111/aas.12370] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2014] [Indexed: 12/19/2022]
Abstract
Fibrinogen concentrate as part of treatment protocols increasingly draws attention. Fibrinogen substitution in cases of hypofibrinogenaemia has the potential to reduce bleeding, transfusion requirement and subsequently reduce morbidity and mortality. A systematic search for randomised controlled trials (RCTs) and non-randomised studies investigating fibrinogen concentrate in bleeding patients was conducted up to November 2013. We included 30 studies of 3480 identified (7 RCTs and 23 non-randomised). Seven RCTs included a total of 268 patients (165 adults and 103 paediatric), and all were determined to be of high risk of bias and none reported a significant effect on mortality. Two RCTs found a significant reduction in bleeding and five RCTs found a significant reduction in transfusion requirements. The 23 non-randomised studies included a total of 2825 patients, but only 11 of 23 studies included a control group. Three out of 11 found a reduction in transfusion requirements while mortality was reduced in two and bleeding in one. In the available RCTs, which all have substantial shortcomings, we found a significant reduction in bleeding and transfusions requirements. However, data on mortality were lacking. Weak evidence from RCTs supports the use of fibrinogen concentrate in bleeding patients, primarily in elective cardiac surgery, but a general use of fibrinogen across all settings is only supported by non-randomised studies with serious methodological shortcomings. It seems pre-mature to conclude whether fibrinogen concentrate has a routine role in the management of bleeding and coagulopathic patients. More RCTs are urgently warranted.
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Affiliation(s)
- J. LUNDE
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - J. STENSBALLE
- Section for Transfusion Medicine; Capital Region Blood Bank; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesia; Centre of Head and Orthopedics; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. WIKKELSØ
- Department of Anaesthesia and Intensive Care Medicine; Herlev Hospital; University of Copenhagen; Copenhagen Denmark
| | - M. JOHANSEN
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesiology; Department of Neuroanaesthesia and Intensive Care; Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
| | - A. AFSHARI
- Juliane Marie Centre - Department of Anesthesia; 4013 Rigshospitalet; Copenhagen University Hospital; Copenhagen Denmark
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Prevention of complications in the air transport of the critically ill paediatric patient between hospitals. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.anpede.2013.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Sakellaris G, Blevrakis E, Petrakis I, Dimopoulou A, Dede O, Partalis N, Alegakis A, Seremeti C, Spanaki AM, Briassoulis G. Acute coagulopathy in children with multiple trauma: a retrospective study. J Emerg Med 2014; 47:539-45. [PMID: 25201343 DOI: 10.1016/j.jemermed.2014.06.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 03/21/2014] [Accepted: 06/30/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute coagulopathy associated with trauma has been recognized for decades and is a constituent of the "triad of death" together with hypothermia and acidosis. STUDY OBJECTIVE The aim of this study was to determine to what extent coagulopathy is already established upon emergency department (ED) admission and the association with the severity of injury, impaired outcome, and mortality. METHODS Ninety-one injured children were admitted to the ED in our hospital. Pediatric Trauma Score (PTS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) score were used to estimate injury severity, and organ function was assessed by the Sequential Organ Failure Assessment (SOFA) score. RESULTS Coagulopathy upon pediatric intensive care unit admission was present in 33 children (39.3%): 21 males and 12 females. PTS ranged from 1 to 12 (mean 8.2) in 51 children without coagulopathy and from -1 to +11 (mean 6.8) in 33 children with coagulopathy (p = 0.087). ISS and GCS ranged from 4 to 57 (mean 28) and from 3 to 11 (mean 7.3), respectively, in the coagulopathy group, whereas in the group without coagulopathy, ISS score ranged from 4 to 41 (mean 20.5; p = 0.08) and GCS from 8 to 15 (mean 12.8; p = 0.01). SOFA ranged from 0 to 10 (mean 3.4) in children without coagulopathy and from 0 to 15 (mean 5.4) in the coagulopathy group (p = 0.002). Among 33 children with coagulopathy, 7 did not survive (21%), all with parenchymal brain damage, whereas all trauma patients without coagulopathy survived (p < 0.001). CONCLUSION Acute coagulopathy is present on admission to the ED and is associated with injury severity and significantly higher mortality.
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Affiliation(s)
- George Sakellaris
- Department of Pediatric Surgery, University Hospital of Heraklion, Greece
| | | | - Ioannis Petrakis
- Department of General Surgery, University Hospital of Heraklion, Greece
| | | | - Olga Dede
- Department of Pediatric Surgery, University Hospital of Heraklion, Greece
| | - Nikolaos Partalis
- Department of Pediatric Surgery, University Hospital of Heraklion, Greece
| | | | - Chrysa Seremeti
- Department of Pediatric Surgery, University Hospital of Heraklion, Greece
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Deras P, Villiet M, Manzanera J, Latry P, Schved JF, Capdevila X, Charbit J. Early coagulopathy at hospital admission predicts initial or delayed fibrinogen deficit in severe trauma patients. J Trauma Acute Care Surg 2014; 77:433-40. [DOI: 10.1097/ta.0000000000000314] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kaczynski J. Prevention of tissue hypoperfusion in the trauma patient: initial management. Br J Hosp Med (Lond) 2014; 74:81-4. [PMID: 23411976 DOI: 10.12968/hmed.2013.74.2.81] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article outlines the challenges of identification and management of tissue hypoperfusion as a consequence of haemorrhagic shock in civilian polytrauma cases. It also describes damage resuscitation, but does not cover specific trauma cases such as pregnancy, burns, head injuries, children and elderly trauma.
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Affiliation(s)
- Jakub Kaczynski
- Department of General Surgery, Morriston Hospital, Swansea SA6 6NL.
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Palmer L, Martin L. Traumatic coagulopathy--part 1: Pathophysiology and diagnosis. J Vet Emerg Crit Care (San Antonio) 2013; 24:63-74. [PMID: 24382014 DOI: 10.1111/vec.12130] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 11/07/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To review the current literature in reference to the pathophysiology and diagnostic modalities available for acute traumatic coagulopathy (ATC) in relationship to traumatic hemorrhagic shock. ETIOLOGY Posttraumatic hemorrhage is responsible for one of the leading causes of preventable human deaths worldwide. Acute traumatic coagulopathy is an endogenous hypocoagulable condition that has been observed during the immediate (< 1 hour) posttraumatic period. Phenotypically, ATC manifests as a state of systemic hypocoagulability and hyperfibrinolysis. Although different functional mechanisms have been proposed for causing ATC, it is universally thought to be a manifestation of severe tissue injury, shock-induced hypoperfusion, systemic inflammation, and endothelial damage. Excessive activation of the thrombin-thrombomodulin activated Protein C pathway, catecholamine-induced endothelial damage as well as disseminated intravascular coagulation (DIC) with a fibrinolytic phenotype are all hypotheses that have been proposed in attempts to explain the functional mechanism of ATC. DIAGNOSIS An accurate and reliable test remains to be validated for ATC. Traditional coagulation assays (activated partial thromboplastin times and prothrombin times) along with platelet count and fibrinogen concentrations have been used more commonly. Viscoelastic tests (thromboelastography and rotational thromboelastometry) are currently being investigated as a more predictive modality for identifying and guiding therapy for ATC. THERAPY Damage control resuscitation and hemostatic resuscitation are gaining favor as the optimal resuscitative strategies for hemorrhagic shock and ATC. Antifibrinolytics may also play a role when hyperfibrinolysis is present. PROGNOSIS Massive hemorrhage accounts for 30-56% of prehospital posttraumatic deaths in people, with coagulopathic hemorrhage remaining one of the major causes of preventable deaths within the first 24 hours posttrauma. Ten to twenty-five percent of human trauma patients experience ATC, which has been shown to prolong hemorrhage, deter resuscitative efforts, promote sepsis, and increase mortality by at least 4-fold. Prognosis in veterinary patients is not currently known.
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Affiliation(s)
- Lee Palmer
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL, 36849
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Effects of fibrinogen concentrate after shock/resuscitation: a comparison between in vivo microvascular clot formation and thromboelastometry*. Crit Care Med 2013; 41:e301-8. [PMID: 23978812 DOI: 10.1097/ccm.0b013e31828a4520] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Dilutional coagulopathy after resuscitation with crystalloids/colloids clinically often appears as diffuse microvascular bleeding. Administration of fibrinogen reduces bleeding and increases maximum clot firmness, measured by thromboelastometry. Study objective was to implement a model where microvascular bleeding can be directly assessed by visualizing clot formation in microvessels, and correlations can be made to thromboelastometry. DESIGN Randomized animal study. SETTING University research laboratory. SUBJECTS Male Syrian Golden hamsters. INTERVENTIONS Microvessels of Syrian Golden hamsters fitted with a dorsal window chamber were studied using videomicroscopy. After 50% hemorrhage followed by 1 hour of hypovolemia resuscitation with 35% of blood volume using a high-molecular-weight hydroxyethyl starch solution (Hextend, Hospira, MW 670 kD) occurred. Animals were then treated with 250 mg/kg fibrinogen IV (Laboratoire français du Fractionnement et des Biotechnologies, Paris, France) or an equal volume of saline before venular vessel wall injuries was made by directed laser irradiation, and the ability of microthrombus formation was assessed. MEASUREMENTS AND MAIN RESULTS Thromboelastometric measurements of maximum clot firmness were performed at the beginning and at the end of the experiment. Resuscitation with hydroxyethyl starch and sham treatment significantly decreased FIBTEM maximum clot firmness from 32 ± 9 mm at baseline versus 13 ± 5 mm after sham treatment (p < 0.001). Infusion of fibrinogen concentrate significantly increased maximum clot firmness, restoring baseline levels (baseline 32 ± 9 mm; after fibrinogen administration 29 ± 2 mm). In vivo microthrombus formation in laser-injured vessels significantly increased in fibrinogen-treated animals compared with sham (77% vs 18%). CONCLUSIONS Fibrinogen treatment leads to increased clot firmness in dilutional coagulopathy as measured with thromboelastometry. At the microvascular level, this increased clot strength corresponds to an increased prevalence of thrombus formation in vessels injured by focused laser irradiation.
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The pathophysiology, diagnosis and treatment of the acute coagulopathy of trauma and shock: a literature review. Eur J Trauma Emerg Surg 2013; 41:259-72. [DOI: 10.1007/s00068-013-0360-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Accepted: 12/01/2013] [Indexed: 10/25/2022]
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Abstract
INTRODUCTION Acute coagulopathy of trauma (aCOT) is a state of disordered coagulation developing soon after severe injury and blood loss and has been defined in the clinical literature as an elevation in prothrombin time (PT) and activated partial thromboplastin time (aPTT). OBJECTIVE The purpose of this study was to develop a rat model of aCOT resulting from polytrauma and hemorrhage and showing an elevation in PT and aPTT. METHODS Sprague-Dawley rats (300-400 g) were anesthetized with isoflurane. Polytrauma was induced by damaging 10 cm of small intestines, the right and medial liver lobes, the right leg skeletal muscle, and fracture of the right femur. Rats were hemorrhaged 40% of their estimated blood volume. No resuscitation was given. Venous and arterial blood samples were taken at times up to 4 h. RESULTS Polytrauma and hemorrhage resulted in a significant rise in PT, aPTT, potassium, lactate, and glucose. There was a significant decrease in plasma bicarbonate, base excess, and sodium. Blood urea nitrogen and creatinine rose steadily throughout the 4 h indicative of progressive renal failure. Hematocrit decreased significantly immediately after hemorrhage and trauma indicating a movement of fluid into the vascular space from extravascular sources, which was mirrored by a decrease in plasma fibrinogen concentration. In contrast, platelet count initially decreased, rose at 2 h, and decreased again at 3 to 4 h, indicating that platelets were released into the vascular space. The change in platelet count was mirrored by the changes in thrombin-antithrombin and plasmin-antiplasmin complexes. Rotational thromboelastometry showed complex changes. Clotting firmness fell initially, rose at 2 h, and fell again at 3 to 4 h similar to the changes in platelet count. α Angle was elevated, and clotting time was shortened over the 4 h. Treatment with cytochalasin D (platelet function inhibitor) eliminated the increases in clotting firmness and thrombin generation seen at 2 h with rising platelet count. CONCLUSIONS This model of aCOT in rats showed complex changes in clotting parameters over 4 h that included a rise in PT and aPTT. At 4 h, there was a decrease in clotting firmness, even though the clot formation was faster (elevated α angle and decrease in clotting time). The decrease in clotting firmness correlated with falling fibrinogen and platelet count. This model affords an opportunity to evaluate interventions in the treatment of aCOT.
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Kasotakis G, Duggan M, Li Y, O'Dowd D, Baldwin K, de Moya MA, King DR, Alam HB, Velmahos G. Optimal pressure of abdominal gas insufflation for bleeding control in a severe swine splenic injury model. J Surg Res 2013; 184:931-6. [DOI: 10.1016/j.jss.2013.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 03/01/2013] [Accepted: 03/07/2013] [Indexed: 10/27/2022]
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Do parameters used to clear noncritically injured polytrauma patients for extremity surgery predict complications? Clin Orthop Relat Res 2013; 471:2878-84. [PMID: 23512748 PMCID: PMC3734416 DOI: 10.1007/s11999-013-2924-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In multiply injured patients, definitive stabilization of major fractures is performed whenever feasible, depending on the clinical condition. QUESTIONS/PURPOSES We therefore asked whether (1) any preoperative indicators predict major complications after major extremity surgery; (2) perioperative routine parameters other than those indicative of hemorrhagic shock predict postoperative complications; and (3) any postoperative clinical findings can predict major complications in the further course of the patient. METHODS We prospectively followed patients with femoral midshaft fracture, Injury Severity Score (ISS) > 16 points, or three fractures and Abbreviated Injury Scale (AIS) ≥ 2 points and another injury (AIS ≥ 2 points), and age 18 to 65 years. We recorded multiple clinical parameters. End points were pneumonia, sepsis, acute respiratory distress syndrome, acute lung injury, and multiple organ failure. RESULTS Forty-three of 165 patients developed complications. (1) Patients with complications had a decreased initial Glasgow Coma Scale and tended to have a lower ISS. (2) None of the assessed perioperative parameters was able to sufficiently predict postoperative complications. (3) The presence of a lung contusion and ventilation > 48 hours were associated with complications in the further course. CONCLUSIONS In stable multiply injured patients, none of the individual routine clinical parameters was able to predict complications. Severe head and thoracic injuries seem to be important drivers for the development postoperative complications.
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An Increase in Initial Shock Index Is Associated With the Requirement for Massive Transfusion in Emergency Department Patients With Primary Postpartum Hemorrhage. Shock 2013; 40:101-5. [DOI: 10.1097/shk.0b013e31829b1778] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kaczynski J. Resuscitation beyond Advanced Trauma Life Support: damage control. Br J Hosp Med (Lond) 2013; 74:144-8. [PMID: 23665783 DOI: 10.12968/hmed.2013.74.3.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jakub Kaczynski
- Department of General Surgery, Morriston Hospital, Swansea, UK.
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Abstract
Coagulopathy is frequently present in trauma. It is indicative of the severity of trauma and contributes to increased morbidity and mortality. Uncontrolled bleeding is the most frequent preventable cause of death in trauma patients reaching hospital alive. Coagulopathy in trauma has been long thought to develop as a result of hemodilution, acidosis, and hypothermia often related to resuscitation practices. However, altered coagulation tests are already present in 25–30% of severe trauma patients upon hospital arrival before resuscitation efforts. Acute coagulopathy associated with trauma (ACoT) has been recognized in recent years as a distinct entity associated with increased mortality, morbidity, and transfusion requirements. Transfusion and nontransfusion strategies aimed at correcting ACoT, particularly in patients with massive bleeding and massive transfusion, are currently available. Early administration of tranexamic acid to bleeding trauma patients safely reduces the risk of death. It has been proposed that early aggressive blood product transfusional management of ACoT with a red blood cell : plasma : platelets ratio close to 1 : 1 : 1 could result in decreased mortality from uncontrolled bleeding.
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Affiliation(s)
- Carolina Ruiz
- Departamento de Medicina Intensiva, Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, 02399 Santiago, Chile
| | - Max Andresen
- Departamento de Medicina Intensiva, Escuela de Medicina, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, 02399 Santiago, Chile
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Mica L, Rufibach K, Keel M, Trentz O. The risk of early mortality of polytrauma patients associated to ISS, NISS, APACHE II values and prothrombin time. J Trauma Manag Outcomes 2013; 7:6. [PMID: 23705945 PMCID: PMC3671213 DOI: 10.1186/1752-2897-7-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 05/04/2013] [Indexed: 11/10/2022]
Abstract
Background The early hemodynamic normalization of polytrauma patients may lead to better survival outcomes. The aim of this study was to assess the diagnostic quality of trauma and physiological scores from widely used scoring systems in polytrauma patients. Methods In total, 770 patients with ISS > 16 who were admitted to a trauma center within the first 24 hours after injury were included in this retrospective study. The patients were subdivided into three groups: those who died on the day of admission, those who died within the first three days, and those who survived for longer than three days. ISS, NISS, APACHE II score, and prothrombin time were recorded at admission. Results The descriptive statistics for early death in polytrauma patients who died on the day of admission, 1–3 days after admission, and > 3 days after admission were: ISS of 41.0, 34.0, and 29.0, respectively; NISS of 50.0, 50.0, and 41.0, respectively; APACHE II score of 30.0, 25.0, and 15.0, respectively; and prothrombin time of 37.0%, 56.0%, and 84%, respectively. These data indicate that prothrombin time (AUC: 0.89) and APACHE II (AUC: 0.88) have the greatest prognostic utility for early death. Conclusion The estimated densities of the scores may suggest a direction for resuscitative procedures in polytrauma patients. Trial registration “Retrospektive Analysen in der Chirurgischen Intensivmedizin”StV01-2008.
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Affiliation(s)
- Ladislav Mica
- Division of Trauma Surgery, University Hospital of Zürich, Zurich, Switzerland
| | - Kaspar Rufibach
- Division of Biostatistics, University of Zürich, Zurich, Switzerland
| | - Marius Keel
- University Hospital of Othopedic Surgery, Inselspital, Bern, Switzerland
| | - Otmar Trentz
- Department of Trauma Surgery, University Hospital of Zürich, Zurich, Switzerland
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48
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[Evolution of US military transfusion support for resuscitation of trauma and hemorrhagic shock]. Transfus Clin Biol 2013; 20:225-30. [PMID: 23597584 DOI: 10.1016/j.tracli.2013.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 02/01/2013] [Indexed: 11/23/2022]
Abstract
Military conflicts create a dynamic medical environment in which the number of severe trauma cases is compressed in both time and space. In consequence, lessons are learned at a rapid pace. Because the military has an effective organizational structure at its disposal and the logistical capacity to rapidly disseminate new ideas, adoption of novel therapies and protective equipment occurs quickly. The recent conflicts in Iraq and Afghanistan are no exception: more than three dozen new clinical practice guidelines were implemented by the US Armed Forces, with attendant survival benefits, in response to observation and research by military physicians. Here we review the lessons learned by coalition medical personnel regarding resuscitation of severe trauma, integrating knowledge gained from massive transfusion, autopsies, and extensive review of medical records contained in the Joint Theater Trauma Registry. Changes in clinical care included the shift to resuscitation with 1:1:1 component therapy, use of fresh whole blood, and the application of both medical devices and pharmaceutical adjuncts to reduce bleeding. Future research will focus on emerging concepts regarding coagulopathy of trauma and evaluation of promising new blood products for far-forward resuscitation. New strategies aimed at reducing mortality on the battlefield will focus on resuscitation in the pre-hospital setting where hemorrhagic death continues to be a major challenge.
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49
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Genét GF, Johansson PI, Meyer MAS, Sølbeck S, Sørensen AM, Larsen CF, Welling KL, Windeløv NA, Rasmussen LS, Ostrowski SR. Trauma-Induced Coagulopathy: Standard Coagulation Tests, Biomarkers of Coagulopathy, and Endothelial Damage in Patients with Traumatic Brain Injury. J Neurotrauma 2013; 30:301-6. [DOI: 10.1089/neu.2012.2612] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Gustav Folmer Genét
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pär Ingemar Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Surgery, Center for Translational Injury Research, University of Texas Medical School at Houston, Houston, Texas
| | - Martin Abild Stengaard Meyer
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sacha Sølbeck
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne Marie Sørensen
- Department of Anaesthesia, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Trauma Centre, Centre of Head and Orthopaedic, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Claus Falck Larsen
- Trauma Centre, Centre of Head and Orthopaedic, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Karen Lise Welling
- Department of Neurointensive Care, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nis Agerlin Windeløv
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sisse Rye Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Lier H, Vorweg M, Hanke A, Görlinger K. Thromboelastometry guided therapy of severe bleeding. Essener Runde algorithm. Hamostaseologie 2013; 33:51-61. [PMID: 23258612 DOI: 10.5482/hamo-12-05-0011] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 11/27/2012] [Indexed: 01/08/2023] Open
Abstract
Both, severe haemorrhage and blood transfusion are associated with increased morbidity and mortality. Therefore, it is of particular importance to stop perioperative bleeding as fast and as possible to avoid unnecessary transfusion. Viscoelastic test (ROTEM® or TEG®) allow for early prediction of massive transfusion and goal-directed therapy with specific haemostatic drugs, coagulation factor concentrates, and blood products. Growing consensus points out, that plasma-based coagulation screening tests like aPTT and PT are inappropriate for monitoring coagulopathy or guide transfusion therapy. Increasing evidence of more than 5000 surgical or trauma patients points towards the beneficial effects of a thrombelastography or -metry based approach in diagnosis and goal-directed therapy of perioperative massive haemorrhage. The Essener Runde task force is a group of clinicians of various specialties (anaesthesiology, intensive care, haemostaseology, haematology, internal medicine, transfusion medicine, surgery) interested in perioperative coagulation management. The ROTEM diagnostic algorithm of the Essener Runde task force was created to standardise and simplify the interpretation of ROTEM® results in perioperative settings and to present their possible implications for therapeutic interventions in severe bleeding. To exemplify, this text mainly focuses on coagulation management in trauma.
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Affiliation(s)
- H Lier
- Department of Anaesthesiology and Intensive Care, Medicine University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany.
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