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Carenzo L, Calgaro G, Rehn M, Perkins Z, Qasim ZA, Gamberini L, Ter Avest E. Contemporary management of traumatic cardiac arrest and peri-arrest states: a narrative review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:66. [PMID: 39327636 PMCID: PMC11426104 DOI: 10.1186/s44158-024-00197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 08/29/2024] [Indexed: 09/28/2024]
Abstract
Trauma is a leading cause of death and disability worldwide across all age groups, with traumatic cardiac arrest (TCA) presenting a significant economic and societal burden due to the loss of productive life years. Despite TCA's high mortality rate, recent evidence indicates that survival with good and moderate neurological recovery is possible. Successful resuscitation in TCA depends on the immediate and simultaneous treatment of reversible causes according to pre-established algorithms. The HOTT protocol, addressing hypovolaemia, oxygenation (hypoxia), tension pneumothorax, and cardiac tamponade, forms the foundation of TCA management. Advanced interventions, such as resuscitative thoracotomy and resuscitative endovascular balloon occlusion of the aorta (REBOA), further enhance treatment. Contemporary approaches also consider metabolic factors (e.g. hyperkalaemia, calcium imbalances) and hemostatic resuscitation. This narrative review explores the advanced management of TCA and peri-arrest states, discussing the epidemiology and pathophysiology of peri-arrest and TCA. It integrates classic TCA management strategies with the latest evidence and practical applications.
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Affiliation(s)
- Luca Carenzo
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milano, 20089, Italy.
| | - Giulio Calgaro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
| | - Marius Rehn
- Pre-Hospital Division, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Zane Perkins
- Centre for Trauma Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- London's Air Ambulance and Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Zaffer A Qasim
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Ewoud Ter Avest
- London's Air Ambulance and Barts Health NHS Trust, Royal London Hospital, London, UK
- Department of Emergency Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
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Sarkar P, Pugazhendhi AS, Coathup M, Mukhopadhyay K. Antibacterial sponge for rapid noncompressible hemostatic treatment: spatiotemporal studies using a noninvasive model. Biomater Sci 2024; 12:4155-4169. [PMID: 38916074 DOI: 10.1039/d4bm00506f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
Hemorrhage is one of the leading causes of preventable death. While minor injuries can be treated mainly by conventional methods, deep and irregular wounds with profuse bleeding present significant challenges, some of which can be life-threatening and fatal. This underscores the need to develop easily applicable FDA-approved hemostatic treatments that can effectively stanch blood loss at the point of care before professional medical care. A silicone-based bandage system (SilFoam), a non-compressible, self-expanding, antibacterial hemostatic treatment, is reported here. Its two-component system reacts in situ upon mixing to form a stretchable sponge that acts as a 'tamponade' by expanding within seconds with the evolution of oxygen gas from the interaction of the reactive components present in the formulation. This generates autogenous pressure on the wound that can effectively arrest heavy bleeding within minutes. Possessing optimal adhesive properties, the expanded sponge can be easily removed, rendering it optimal for hemostatic wound dressing. With recent advances in biotechnological research, there is a growing awareness of the potential issues associated with in vivo trials, spanning ethical, psychological, economic, and physiological concerns like burnout and fatigue. Bearing this in mind, a unique manikin system simulating a deep abdominal wound has been employed to investigate SilFoam's hemostatic efficacy with different blood-flow rates using a non-invasive model that aims to provide an easy, fast, and economical route to test hemostatic treatments before in vivo studies. This is the first time an Ag2O-based oxygen-induced foaming system has been reported as a hemostatic agent.
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Affiliation(s)
- Pritha Sarkar
- Department of Materials Science and Engineering, University of Central Florida, Orlando, USA.
| | | | - Melanie Coathup
- Biionix Cluster and College of Medicine, University of Central Florida, Orlando, USA
| | - Kausik Mukhopadhyay
- Department of Materials Science and Engineering, University of Central Florida, Orlando, USA.
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Lenn D, Le DT, Scheiber CJ, Smeltz AM. The Perfect Med Bag is One that Doesn't Fall Off a Cliff: A Combat Mass Casualty Case. Mil Med 2024; 189:e2268-e2273. [PMID: 37975228 DOI: 10.1093/milmed/usad444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/19/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023] Open
Abstract
Military trauma provides a unique pattern of injuries due to the high velocity, high kinetic energy ammunition utilized, and the high prevalence of blast injury. To further complicate this, military trauma often occurs in austere environments with limited logistical support. Therefore, military medical providers are forced to learn nonstandard techniques and when necessary, practice a level of improvisation not commonly seen in other medical fields. The case presented in this manuscript is a prime example of these challenges. At the onset of fighting both the medic's rucksack, carrying with it the primary source of medical gear and the precious supply of cold-stored blood products are lost. The scenario was further complicated by rough mountainous terrain and a prolonged evacuation time. The medical provider was forced to utilize nonstandard devices such as an improvised junctional tourniquet which used a rock to focus the devices pressure. They also adapted their basic understanding of surgical procedures to conduct a vascular cutdown procedure for wound exposure and effectively pack an otherwise non-compressible wound to a major artery. Despite a significant loss of equipment, the medic and their team were able to successfully care for a number of patients in this mass casualty scenario.
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Affiliation(s)
- David Lenn
- SCPO (USN), 2d Marine Raider Battalion, Marine Forces Special Operations Command (MARSOC), Camp Lejeune, NC 28547, USA
| | - Daniel T Le
- ENS (USNR), University of North Carolina School of Medicine, Bondurant Hall, CB #9500, Chapel Hill, NC 27599, USA
| | - Christopher J Scheiber
- Department of Anesthesiology, N2198, CB7010, The University of North Carolina at Chapel Hill, UNC Hospitals, Chapel Hill, NC 27599-7010, USA
| | - Alan M Smeltz
- Cardiothoracic Division, Department of Anesthesiology, N2198, CB7010, The University of North Carolina at Chapel Hill, UNC Hospitals, Chapel Hill, NC 27599-7010, USA
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Schepers LE, Martindale BL, Berman AG, Cebull HL, Van Alstine W, Hollingshead SE, Novak T, Goergen CJ. Photocurable extracellular matrix sealant for cessation of venous hemorrhage. J Biomed Mater Res B Appl Biomater 2024; 112:e35401. [PMID: 38520703 DOI: 10.1002/jbm.b.35401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 01/23/2024] [Accepted: 02/18/2024] [Indexed: 03/25/2024]
Abstract
Hemorrhage is the second leading cause of death in patients under 46 years of age in the United States. Cessation of hemorrhage prevents hemorrhagic shock and tissue hypoxia. Controlling the bleed via direct pressure or tourniquet is often the first line of defense, but long-term care requires staples, hemostatic agents, or sealants that seal the vessel and restore blood flow. Here, we compare a new photocurable extracellular matrix sealant (pcECM) with low, medium, and high crosslink density formulations to a commercially available fibrin-based sealant, TISSEEL®. pcECM has potential uses in surgical and remote settings due to room temperature storage conditions and fast preparation time. Here, we determine if pcECM sealant can stop venous hemorrhage in a murine model, adhere to the wound site in vivo throughout the wound-healing process, and has the mechanical properties necessary for stopping hemorrhage. Adjusting pcECM crosslinking density significantly affected viscosity, swelling, burst strength, tensile strength, and elasticity of the sealant. 3-Dimensional ultrasound volume segmentations showed pcECM degrades to 17 ± 8% of its initial implant volume by day 28. Initially, local hemodynamic changes were observed, but returned close to baseline levels by day 28. Acute inflammation was observed near the puncture site in pcECM implanted mice, and we observed inflammatory markers at the 14-day explant for both sealants. pcECM and fibrin sealant successfully sealed the vessel in all cases, and consistently degraded over 14-28 days. pcECM is a durable sealant with tunable mechanical properties and possible uses in hemorrhage control and other surgical procedures.
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Affiliation(s)
- Luke E Schepers
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | | | - Alycia G Berman
- Product Engineering, Cook Biotech Inc., West Lafayette, Indiana, USA
| | - Hannah L Cebull
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | | | | | - Tyler Novak
- Product Engineering, Cook Biotech Inc., West Lafayette, Indiana, USA
| | - Craig J Goergen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
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Rall JM, Baker KJ, Sandoval ML, Flinn AN, Causey MW. Transition of Resuscitative Endovascular Balloon Occlusion of the Aorta from Zone 3 to Zone 1 to Treat Hemodynamic Collapse during Continued Hemorrhage. Mil Med 2024; 189:e285-e290. [PMID: 37552642 DOI: 10.1093/milmed/usad313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023] Open
Abstract
INTRODUCTION Noncompressible torso hemorrhage (NCTH) accounts for most potentially survivable deaths on the battlefield. Treatment of NCTH is challenging, especially in far-forward environments with limited capabilities. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has shown promise in the care of patients with NCTH. REBOA involves introducing a balloon catheter into the descending aorta in a specific occlusion region (zones 1, 2, or 3) and acts as a hemorrhage control adjunct with resuscitative support. The balloon is placed in zone 3 in the infrarenal aorta for high junctional or pelvic injuries and in zone 1 proximal to the diaphragm for torso hemorrhage. Zone 1 REBOA provides more resuscitative support than zone 3; however, the potential for ischemia and reperfusion injuries is greater with zone 1 than with zone 3 REBOA placement. This study aims to determine the possible benefit of transitioning the REBOA balloon from zone 3 to zone 1 to rescue a patient with ongoing venous bleeding and impending cardiovascular collapse. MATERIALS AND METHODS Yorkshire male swine (70-90 kg, n = 6 per group) underwent injury to the femoral artery, which was allowed to bleed freely for 60 s, along with a simultaneous controlled venous hemorrhage. After 60 s, the arterial bleed was controlled with hemostatic gauze and zone 3 REBOA was inflated. Five hundred milliliters of Hextend was used for initial fluid resuscitation. The controlled venous bleed continued until a mean arterial pressure (MAP) of 30 mmHg was reached to create an impending cardiovascular collapse. The animals were then randomized into either continued zone 3 REBOA or transition from zone 3 to zone 1 REBOA. Following 30 min, a "hospital phase" was initiated, consisting of cessation of the venous hemorrhage, deflation of the REBOA balloon, and transfusion of one unit of whole blood administered along with saline and norepinephrine to maintain a MAP of 60 mmHg or higher. The animals then underwent a 2-h observation period. Survival, hemodynamics, and blood chemistries were compared between groups. RESULTS No significant differences between groups were observed in hemodynamic or laboratory values at baseline, postinitial injury, or when MAP reached 30 mmHg. Survival was significantly longer in animals that transitioned into zone 1 REBOA (log-rank analysis, P = .012). The average time of survival was 14 ± 10 min for zone 3 animals vs. 65 ± 59 min for zone 1 animals (P = .064). No animals in the zone 3 group survived to the hospital phase. Zone 1-treated animals showed immediate hemodynamic improvement after transition, with maximum blood pressure reaching near baseline values compared to those in the zone 3 group. CONCLUSIONS In this swine model of NCTH, hemodynamics and survival were improved when the REBOA balloon was transitioned from zone 3 to zone 1 during an impending cardiovascular collapse. Furthermore, these improved outcome data support the pursuit of additional research into mitigating ischemia-reperfusion insult to the abdominal viscera while still providing excellent resuscitative support, such as intermittent or partial REBOA.
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Affiliation(s)
- Jason M Rall
- Office of Science and Technology, 59th Medical Wing, JBSA Lackland, TX 78236, USA
| | - Kimberly J Baker
- Office of Science and Technology, 59th Medical Wing, JBSA Lackland, TX 78236, USA
| | - Melody L Sandoval
- Office of Science and Technology, 59th Medical Wing, JBSA Lackland, TX 78236, USA
| | - Ashley N Flinn
- Division of Vascular Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA
| | - Marlin W Causey
- Division of Vascular Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA
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Kim JS, Casem CF, Baral E, Inaba K, Kuza CM. Narrative Review: Is There a Transfusion Cutoff Value After Which Nonsurvivability Is Inevitable in Trauma Patients Receiving Ultramassive Transfusion? Anesth Analg 2023; 137:354-364. [PMID: 37115716 DOI: 10.1213/ane.0000000000006504] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
The institution of massive transfusion protocols (MTPs) has improved the timely delivery of large quantities of blood products and improves patient outcomes. In recent years, the cost of blood products has increased, compounded by significant blood product shortages. There is practical need for identification of a transfusion volume in trauma patients that is associated with increased mortality, or a threshold after which additional transfusion is futile and associated with nonsurvivability. This transfusion threshold is often described in the setting of an ultramassive transfusion (UMT). There are few studies defining what constitutes amount or outcomes associated with such large volume transfusion. The purpose of this narrative review is to provide an analysis of existing literature examining the effects of UMT on outcomes including survival in adult trauma patients and to determine whether there is a threshold transfusion limit after which mortality is inevitable. Fourteen studies were included in this review. The data examining the utility of UMT in trauma are of poor quality, and with the variability inherent in trauma patients, and the surgeons caring for them, no universally accepted cutoff for transfusion exists. Not surprisingly, there is a trend toward increasing mortality with increasing transfusions. The decision to continue transfusing is multifactorial and must be individualized, taking into consideration patient characteristics, institution factors, blood bank supply, and most importantly, constant reevaluation of the need for ongoing transfusion rather than blind continuous transfusion until the heart stops.
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Affiliation(s)
- Jennie S Kim
- From the Department of Surgery, University of Southern California Trauma and Acute Care Surgery, Los Angeles, California
| | - Christleen F Casem
- Department of Surgery, University of California San Francisco East Bay Surgery, Oakland, Californiaand
| | - Erika Baral
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kenji Inaba
- From the Department of Surgery, University of Southern California Trauma and Acute Care Surgery, Los Angeles, California
| | - Catherine M Kuza
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
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7
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Szymanski L, Gołaszewska K, Małkowska J, Kaczyńska J, Gołębiewska M, Gromadka B, Matak D. Safety and Performance of Hemostatic Powders. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2023; 16:133-144. [PMID: 37313450 PMCID: PMC10259579 DOI: 10.2147/mder.s407838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/16/2023] [Indexed: 06/15/2023] Open
Abstract
Background Hemorrhage, a sudden and severe leakage of blood due to the disruption of blood vessels, is one of the most common causes of death from injuries worldwide. Severe bleeding accounts for more than 35% of pre-hospital deaths and about 40% of deaths recorded within 24 hours of injury. One of the methods for achieving homeostasis is the use of hemostatic powders. This study compares the basic safety and performance of the most popular hemostatic powders. Methods Basic safety of commercially available products were evaluated using MTT, MEM elution assay, and endotoxin testing. The in vitro performance was evaluated using water absorption capacity, water absorption rate, and adhesion strength assays. Results 4Seal, Starsil, and 4DryField extracts did not cause cytotoxicity in MTT and MEM elution assays. PerClot and SuperClot extracts demonstrated cytotoxic potential in MTT assay, while Arista extract was cytotoxic in both MEM elution and MTT assays. 4Seal has the lowest endotoxin contamination, followed by PerClot, 4DryField, SuperClot, Arista, and Starsil. 4Seal and Starsil showed significantly highest WAR among the tested samples, followed by 4DryField, Arista, PerClot, and SuperClot. Adhesion force is highest for 4Seal, followed by Starsil, PerClot, 4DryField Arista, and SuperClot. Conclusion 4Seal is the most versatile in terms of safety and functional properties compared to 4DryField, Arista, PerClot, Starsil, and SuperClot.
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Affiliation(s)
- Lukasz Szymanski
- Department of Molecular Biology, Institute of Genetics and Animal Biotechnology, Polish Academy of Science, Magdalenka, 05-552, Poland
- European Biomedical Institute, Jozefow, 05-410, Poland
| | | | | | | | | | | | - Damian Matak
- European Biomedical Institute, Jozefow, 05-410, Poland
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González-Alonso V, Usero-Pérez MDC, Seguido Chacón R, Gómez de la Fuente A, Cortés-Martín J, Rodríguez-Blanque R, Sánchez-García JC. Evaluation of the Impact of a Tourniquet Training Program: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2742. [PMID: 36768112 PMCID: PMC9914968 DOI: 10.3390/ijerph20032742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
Among the main preventable causes of death in the area of operations is external exsanguinating hemorrhage in the extremities, hence the importance of the tourniquet as a therapeutic tool in this type of injury and, therefore, of the training of personnel participating in international missions. The main objective of this study is to determine the impact of training in the application of this device. This is a quasi-experimental, prospective, cross-sectional study, carried out with 97 healthy volunteers, military personnel who perform their work in the Royal Guard barracks of El Pardo. The study was conducted between June 2019 and July 2021. The correct determination of the device placement site and the times of correct device placement were evaluated by determining whether there was blood flow using Doppler ultrasound measurements. Statistically significant results were obtained for application time (76.68 s to 58.06 s; p < 0.001), correct device placement (p < 0.001), and achievement of complete ischemia in the upper extremity (23.7% pretest vs. 24.7% post-test; p < 0.001). In the lower extremity, after training, longer application duration (43.33 s to 47.30 s) and lower ischemia achievement (59.8% pretest vs. 37.8% post-test) were obtained. Standardized and regulated training improves device application. More intensive training is necessary to obtain better results.
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Affiliation(s)
- Valentín González-Alonso
- Departamento Simulación, Escuela Militar de Sanidad (EMISAN), Ministerio de Defensa, 28047 Madrid, Spain
| | | | | | | | - Jonathan Cortés-Martín
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Granada, 18071 Granada, Spain
| | - Raquel Rodríguez-Blanque
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Granada, 18071 Granada, Spain
- Hospital Clinico Universitario San Cecilio, 18016 Granada, Spain
| | - Juan Carlos Sánchez-García
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Granada, 18071 Granada, Spain
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Manteiga-Urbón JL, Fernández-Méndez F, Otero-Agra M, Fernández-Méndez M, Santos-Folgar M, Insa-Calderon E, Sobrido-Prieto M, Barcala-Furelos R, Martínez-Isasi S. Brief Training of Technical Bleeding Control Skills-A Pilot Study with Security Forces. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2494. [PMID: 36767862 PMCID: PMC9915853 DOI: 10.3390/ijerph20032494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/17/2023] [Accepted: 01/24/2023] [Indexed: 06/18/2023]
Abstract
Uncontrolled external bleeding is a common cause of preventable death, and due to the environment in which these events often occur, e.g., in hostile environments, the state security forces are usually the first responders, and in many cases, if they are injured their partners provide the initial assistance. The tourniquet is a fast, effective, and easy-to-learn intervention, although there is a knowledge gap concerning training techniques. The objective is to evaluate the effectiveness of a bleeding control training program on a high-fidelity mannequin in a simulated critical situation in a law enforcement training environment. A quasi-experimental study was carried out with 27 members of the state security forces. They underwent brief theoretical-practical training and were evaluated via a scenario involving a critically ill patient in a hostile environment. The results showed that no member of the state security forces completed all the tourniquet placement steps, 26 (96%) prepared the tourniquet correctly, 21 (77.8%) placed it on the leg, and all the participants adjusted the band to the thickness of the injured limb and secured the windlass to the triangular flange of the device. However, only 23 (85.2%) of the participants placed it effectively. The participants, who were members of the state security forces, were able to effectively resolve a critical situation with active bleeding in a simulation scenario with a high-fidelity mannequin after completing theoretical-practical training.
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Affiliation(s)
| | - Felipe Fernández-Méndez
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- School of Nursing, University of Vigo, 36005 Pontevedra, Spain
| | - Martín Otero-Agra
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- School of Nursing, University of Vigo, 36005 Pontevedra, Spain
| | - María Fernández-Méndez
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- School of Nursing, University of Vigo, 36005 Pontevedra, Spain
| | - Myriam Santos-Folgar
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- School of Nursing, University of Vigo, 36005 Pontevedra, Spain
| | - Esther Insa-Calderon
- ESIMar (Mar Nursing School), Parc de Salut Mar, Universitat Pompeu Fabra Affiliated, 08003 Barcelona, Spain
- SDHEd (Social Determinants and Health Education Research Group), IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
| | - María Sobrido-Prieto
- Departamento de Ciencias da Saúde, Universidade de A Coruña (UDC), Campus de Esteiro, 15403 Ferrol, Spain
| | - Roberto Barcala-Furelos
- REMOSS Research Group, University of Vigo, 36005 Pontevedra, Spain
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela-CHUS, 15706 Santiago Compostela, Spain
- Faculty of Education and Sport Sciences, University of Vigo, 36005 Pontevedra, Spain
| | - Santiago Martínez-Isasi
- Simulation and Intensive Care Unit of Santiago (SICRUS) Research Group, Health Research Institute of Santiago, University Hospital of Santiago de Compostela-CHUS, 15706 Santiago Compostela, Spain
- CLINURSID Research Group, Psychiatry, Radiology, Public Health, Nursing and Medicine Department, Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain
- Faculty of Nursing, Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain
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10
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Akl M, Anand T, Reina R, El-Qawaqzeh K, Ditillo M, Hosseinpour H, Nelson A, Obaid O, Friese R, Joseph B. Balanced hemostatic resuscitation for bleeding pediatric trauma patients: A nationwide quantitative analysis of outcomes. J Pediatr Surg 2022; 57:986-993. [PMID: 35940936 DOI: 10.1016/j.jpedsurg.2022.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 06/04/2022] [Accepted: 07/04/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND The administration of balanced component therapy has been associated with improvements in outcomes in adult trauma. There is little to no specific data to guide transfusion ratios in children. The aim of our study is to compare outcomes among different transfusion strategies in pediatric trauma patients. METHODS We conducted a (2014-2016) retrospective analysis of the Trauma Quality Improvement Program. We selected all pediatric (age < 18) trauma patients who received at least one unit of packed red blood cells (PRBC) and fresh frozen plasma (FFP) within 4 h of admission. Patients were stratified based on their FFP:PRBC transfusion ratio in the first 4 h into: 1:1, 1:2, 1:3, and 1:3+. Primary outcomes were 24-mortality, in-hospital mortality. Secondary outcomes were complications and 24 h PRBC transfusion requirements. Multivariable logistic regression analysis was performed. RESULTS A total of 1,233 patients were identified of which 637 received transfusion ratio of 1:1, 365 1:2, 116 1:3, and 115 1:3+. Mean age was 11 ± 6y, 70% were male, ISS was 27 [20-38], and 62% sustained penetrating injuries. Patients in the 1:1 group had the lowest 24 h mortality (14% vs. 18% vs. 22% vs. 24%; p = 0.01) and in-hospital mortality (32% vs. 36% vs. 40% vs. 44%; p = 0.01). No difference was found between the groups in terms of complications (22% vs. 21% vs. 23% vs. 22%; p = 0.96) such as acute respiratory distress syndrome (3.3% vs. 3.6% vs. 0.9% vs. 0%; p = 0.10), and acute kidney injury (3% vs. 2.2% vs. 0.9% vs. 0.9%; p = 0.46). Additionally the 1:1 group had the lowest PRBC transfusion requirements (3[2-7] vs. 5[2-10] vs. 6[3-8] vs. 6[4-10]; p < 0.01). On regression analysis a progressive increase in the mortality adjusted odds ratio was observed as the FFP:PRBC transfusion ratio decreased. CONCLUSION FFP:PRBC ratios closest to 1 were associated with increased survival in children. The resuscitation of pediatric patients should target a 1:1 ratio of FFP:PRBC. Further studies are needed for the development of massive transfusion protocols for this age group. LEVEL OF EVIDENCE Level IV STUDY TYPE: Therapeutic/Care Management.
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Affiliation(s)
- Malak Akl
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA
| | - Tanya Anand
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA
| | - Raul Reina
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA
| | - Khaled El-Qawaqzeh
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA
| | - Michael Ditillo
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA
| | - Adam Nelson
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA
| | - Omar Obaid
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA
| | - Randall Friese
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ 85724, USA.
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11
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Gauss T, Richards JE, Tortù C, Ageron FX, Hamada S, Josse J, Husson F, Harrois A, Scalea TM, Vivant V, Meaudre E, Morrison JJ, Galvagno S, Bouzat P. Association of Early Norepinephrine Administration With 24-Hour Mortality Among Patients With Blunt Trauma and Hemorrhagic Shock. JAMA Netw Open 2022; 5:e2234258. [PMID: 36205999 PMCID: PMC9547317 DOI: 10.1001/jamanetworkopen.2022.34258] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
IMPORTANCE Hemorrhagic shock is a common cause of preventable death after injury. Vasopressor administration for patients with blunt trauma and hemorrhagic shock is often discouraged. OBJECTIVE To evaluate the association of early norepinephrine administration with 24-hour mortality among patients with blunt trauma and hemorrhagic shock. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter, observational cohort study used data from 3 registries in the US and France on all consecutive patients with blunt trauma from January 1, 2013, to December 31, 2018. Patients were alive on admission with hemorrhagic shock, defined by prehospital or admission systolic blood pressure less than 100 mm Hg and evidence of hemorrhage (ie, prehospital or resuscitation room transfusion of packed red blood cells, receipt of emergency treatment for hemorrhage control, transfusion of >10 units of packed red blood cells in the first 24 hours, or death from hemorrhage). Blunt trauma was defined as any exposure to nonpenetrating kinetic energy, collision, or deceleration. Statistical analysis was performed from January 15, 2021, to February 22, 2022. EXPOSURE Continuous administration of norepinephrine in the prehospital environment or resuscitation room prior to hemorrhage control, according to European guidelines. MAIN OUTCOMES AND MEASURES The primary outcome was 24-hour mortality, and the secondary outcome was in-hospital mortality. The average treatment effect (ATE) of early norepinephrine administration on 24-hour mortality was estimated according to the Rubin causal model. Inverse propensity score weighting and the doubly robust approach with 5 distinct analytical strategies were used to determine the ATE. RESULTS A total of 52 568 patients were screened for inclusion, and 2164 patients (1508 men [70%]; mean [SD] age, 46 [19] years; median Injury Severity Score, 29 [IQR, 17-36]) presented with acute hemorrhage and were included. A total of 1497 patients (69.1%) required emergency hemorrhage control, 128 (5.9%) received a prehospital transfusion of packed red blood cells, and 543 (25.0%) received a massive transfusion. Norepinephrine was administered to 1498 patients (69.2%). The 24-hour mortality rate was 17.8% (385 of 2164), and the in-hospital mortality rate was 35.6% (770 of 2164). None of the 5 analytical strategies suggested any statistically significant association between norepinephrine administration and 24-hour mortality, with ATEs ranging from -4.6 (95% CI, -11.9 to 2.7) to 2.1 (95% CI, -2.1 to 6.3), or between norepinephrine administration and in-hospital mortality, with ATEs ranging from -1.3 (95% CI, -9.5 to 6.9) to 5.3 (95% CI, -2.1 to 12.8). CONCLUSIONS AND RELEVANCE The findings of this study suggest that early norepinephrine infusion was not associated with 24-hour or in-hospital mortality among patients with blunt trauma and hemorrhagic shock. Randomized clinical trials that study the effect of early norepinephrine administration among patients with trauma and hypotension are warranted to further assess whether norepinephrine is safe for patients with hemorrhagic shock.
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Affiliation(s)
- Tobias Gauss
- Anesthesia and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Justin E. Richards
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | | | - François-Xavier Ageron
- Emergency Department, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sophie Hamada
- Department of Anesthesia and Critical Care, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris, Paris, France
- Centre de Recherche en épidémiologie et Santé des populations, INSERM U 10-18, Université Paris-Saclay, Paris, France
| | - Julie Josse
- National Institute for Research in Digital Science and Technology (INRIA), Montpellier, France
| | - François Husson
- Institut Agro, Université Rennes, French National Centre for Scientific Research, Institut de recherche mathématique de Rennes, Rennes, France
| | - Anatole Harrois
- Department of Anesthesiology and Critical Care, Bicêtre Hospital, AP-HP, University Paris Saclay, Le Kremlin Bicêtre, France
| | - Thomas M. Scalea
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | | | - Eric Meaudre
- Department of Intensive Care Unit and Anesthesia, Military Teaching Hospital Sainte-Anne, Toulon, France
| | - Jonathan J. Morrison
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Samue Galvagno
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore
| | - Pierre Bouzat
- Anesthesia and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
- University Grenoble Alpes, INSERM, U1216, CHU Grenoble Alpes, Grenoble Institute Neurosciences, Grenoble, France
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12
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Levy MJ, Krohmer J, Goralnick E, Charlton N, Nemeth I, Jacobs L, Goolsby CA. A framework for the design and implementation of Stop the Bleed and public access trauma equipment programs. J Am Coll Emerg Physicians Open 2022; 3:e12833. [PMID: 36311340 PMCID: PMC9611563 DOI: 10.1002/emp2.12833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/06/2022] [Accepted: 09/27/2022] [Indexed: 12/03/2022] Open
Abstract
Traumatic injuries remain the leading cause of death for those under the age of 44 years old. Nearly a third of those who die from trauma do so from bleeding. Reducing death from severe bleeding requires training in the recognition and treatment of life-threatening bleeding, as well as programs to ensure immediate access to bleeding control resources. The Stop the Bleed (STB) initiative seeks to educate and empower people to be immediate responders and provide control of life-threatening bleeding until emergency medical services arrive. Well-planned and implemented STB programs will help ensure program effectiveness, minimize variability, and provide long-term sustainment. Comprehensive STB programs foster consistency, promote access to bleeding control education, contain a framework to guide the acquisition and placement of equipment, and promote the use of these resources at the time of a bleeding emergency. We leveraged the expertise and experience of the Stop the Bleed Education Consortium to create a resource document to help inform and guide STB program developers and implementers on the key areas for consideration when crafting strategy. These areas include (1) equipment selection, (2) logistics and kit placement, (3) educational program accessibility and implementation, and (4) program oversight, facilitation, and administration.
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Affiliation(s)
- Matthew J. Levy
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- National Center for Disaster Medicine and Public HealthBethesdaMarylandUSA
| | - Jon Krohmer
- Department of Emergency MedicineMichigan State UniversityGrand RapidsMichiganUSA
| | - Eric Goralnick
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Nathan Charlton
- Department of Emergency MedicineUniversity of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | - Ira Nemeth
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Lenworth Jacobs
- Hartford Health CareAcademic Affairs, Hartford HospitalHartfordConnecticutUSA
| | - Craig A. Goolsby
- Department of Emergency Medicine, Harbor‐UCLA Medical CenterDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
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13
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Jahr JS. Blood substitutes: Basic science, translational studies and clinical trials. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:989829. [PMID: 36062262 PMCID: PMC9433579 DOI: 10.3389/fmedt.2022.989829] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/28/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Jonathan S. Jahr
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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14
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Martin SC, Hauser N, Renaldo AC, Lane M, Jordan JE, Qadri HI, Mouser N, Rahbar E, Williams TK, Neff LP. Unmasking the Confounder: The Inherent Physiologic Variability of Swine During an Automated Experimental Model of Ischemia-Reperfusion Injury. Am Surg 2022; 88:1838-1844. [PMID: 35392677 DOI: 10.1177/00031348221084967] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We sought to determine the magnitude of the inherent inter-animal physiologic variability by automating a porcine Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) protocol to minimize external influences that might alter physiology and confound experimental results. METHODS Swine (n = 42) underwent a controlled 30% blood volume hemorrhage followed by 30 minutes of REBOA (ie, ischemic phase). The animals were weaned from REBOA autonomously over 15 minutes, beginning the reperfusion phase, while continuing to provide partial flow balloon support to maintain a target proximal mean arterial pressure (pMAP) of 65 mmHg. Simultaneously, shed blood was re-transfused as part of the resuscitation efforts. Physiologic data were continuously recorded, and serum samples were serially collected. Baseline characteristics, variance in vital signs, and 8-isoprostane levels were quantified during hemorrhage, REBOA, and reperfusion phases. RESULTS There was no significant difference in baseline physiology across animals (P > .05). Hemodynamic variability was highest for pMAP during the ischemic phase (P = .001) and for distal mean arterial pressure (dMAP) during the weaning/reperfusion phase (P = .001). The latter finding indicated the variable physiologic response to ischemia-reperfusion injury, as the automated balloon support required by each animal to maintain pMAP was highly variable. Circulating 8-isoprostane variance was significantly higher following the start of reperfusion compared to baseline levels (P = .001). DISCUSSION Despite subjecting animals to a highly consistent ischemia-reperfusion injury through automation, we noted significant variability in the hemodynamic and biochemical response. These findings illustrate the inherent physiologic variability and potential limitations of porcine large animal models for the study of shock.
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Affiliation(s)
| | - Nathaniel Hauser
- Department of Biomedical Engineering, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Antonio C Renaldo
- Department of Biomedical Engineering, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Magan Lane
- Department of Vascular and Endovascular Surgery, 12280Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - James E Jordan
- Department of Cardiothoracic Surgery, 12280Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Hisham I Qadri
- 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Elaheh Rahbar
- Department of Biomedical Engineering, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, 12280Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Lucas P Neff
- Department of General Surgery, 12280Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
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15
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Day A. ENA Position Statement: Hemorrhage Control. J Emerg Nurs 2022; 48:460-464. [PMID: 35787775 DOI: 10.1016/j.jen.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/15/2022] [Accepted: 03/11/2022] [Indexed: 11/19/2022]
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16
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HMGB1 Inhibition to Ameliorate Organ Failure and Increase Survival in Trauma. Biomolecules 2022; 12:biom12010101. [PMID: 35053249 PMCID: PMC8773879 DOI: 10.3390/biom12010101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 12/15/2022] Open
Abstract
Several preclinical and clinical reports have demonstrated that levels of circulating high mobility group box 1 protein (HMGB1) are increased early after trauma and are associated with systemic inflammation and clinical outcomes. However, the mechanisms of the interaction between HMGB1 and inflammatory mediators that lead to the development of remote organ damage after trauma remain obscure. HMGB1 and inflammatory mediators were analyzed in plasma from 54 combat casualties, collected on admission to a military hospital in Iraq, and at 8 and 24 h after admission. In total, 45 (83%) of these patients had traumatic brain injury (TBI). Nine healthy volunteers were enrolled as controls. HMGB1 plasma levels were significantly increased in the first 8 h after admission, and were found to be associated with systemic inflammatory responses, injury severity score, and presence of TBI. These data provided the rationale for designing experiments in rats subjected to blast injury and hemorrhage, to explore the effect of HMGB1 inhibition by CX-01 (2-O, 3-O desulfated heparin). Animals were cannulated, then recovered for 5–7 days before blast injury in a shock tube and volume-controlled hemorrhage. Blast injury and hemorrhage induced an early increase in HMGB1 plasma levels along with severe tissue damage and high mortality. CX-01 inhibited systemic HMGB1 activity, decreased local and systemic inflammatory responses, significantly reduced tissue and organ damage, and tended to increase survival. These data suggest that CX-01 has potential as an adjuvant treatment for traumatic hemorrhage.
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17
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Beaman HT, Shepherd E, Satalin J, Blair S, Ramcharran H, Serinelli S, Gitto L, Dong KS, Fikhman D, Nieman G, Schauer SG, Monroe MBB. Hemostatic shape memory polymer foams with improved survival in a lethal traumatic hemorrhage model. Acta Biomater 2022; 137:112-123. [PMID: 34655799 DOI: 10.1016/j.actbio.2021.10.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/30/2021] [Accepted: 10/05/2021] [Indexed: 11/01/2022]
Abstract
Although there are many hemostatic agents available for use on the battlefield, uncontrolled hemorrhage is still the primary cause of preventable death. Current hemostatic dressings include QuikClot® Combat Gauze (QCCG) and XStat®, which have inadequate success in reducing mortality. To address this need, a new hemostatic material was developed using shape memory polymer (SMP) foams, which demonstrate biocompatibility, rapid clotting, and shape recovery to fill the wound site. SMP foam hemostatic efficacy was examined in a lethal, noncompressible porcine liver injury model over 6 h following injury. Wounds were packed with SMP foams, XStat, or QCCG and compared in terms of time to bleeding cessation, total blood loss, and animal survival. The hemostatic material properties and in vitro blood interactions were also characterized. SMP foams decreased blood loss and active bleeding time in comparison with XStat and QCCG. Most importantly, SMP foams increased the 6 h survival rate by 50% and 37% (vs. XStat and QCCG, respectively) with significant increases in survival times. Based upon in vitro characterizations, this result is attributed to the low stiffness and shape filling capabilities of SMP foams. This study demonstrates that SMP foams have promise for improving upon current clinically available hemostatic dressings and that hemostatic material properties are important to consider in designing devices for noncompressible bleeding control. STATEMENT OF SIGNIFICANCE: Uncontrolled hemorrhage is the leading cause of preventable death on the battlefield, and it accounts for approximately 1.5 million deaths each year. New biomaterials are required for improved hemorrhage control, particularly in noncompressible wounds in the torso. Here, we compared shape memory polymer (SMP) foams with two clinical dressings, QuikClot Combat Gauze and XStat, in a pig model of lethal liver injury. SMP foam treatment reduced bleeding times and blood loss and significantly improved animal survival. After further material characterization, we determined that the improved outcomes with SMP foams are likely due to their low stiffness and controlled shape change after implantation, which enabled their delivery to the liver injuries without inducing further wound tearing. Overall, SMP foams provide a promising option for hemorrhage control.
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18
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Goralnick E, Ezeibe C, Chaudhary MA, McCarty J, Herrera-Escobar JP, Andriotti T, de Jager E, Ospina-Delgado D, Goolsby C, Hunt R, Weissman JS, Haider A, Jacobs L, Andrade E, Brown J, Bulger EM, Butler FK, Callaway D, Caterson EJ, Choudhry NK, Davis MR, Eastman A, Eastridge BJ, Epstein JL, Evans CL, Gausche-Hill M, Gestring ML, Goldberg SA, Hanfling D, Holcomb JB, Jonson CO, King DR, Kivlehan S, Kotwal RS, Krohmer JR, Levy-Carrick N, Levy M, Meléndez Lugo JJ, Mooney DP, Neal MD, Niskanen R, O'Neill P, Park H, Pons PT, Prytz E, Rasmussen TE, Remley MA, Riviello R, Salim A, Shackelfold S, Smith ER, Stewart RM, Swaroop M, Ward K, Uribe-Leitz T, Jarman MP, Ortega G. Defining a Research Agenda for Layperson Prehospital Hemorrhage Control: A Consensus Statement. JAMA Netw Open 2020; 3:e209393. [PMID: 32663307 DOI: 10.1001/jamanetworkopen.2020.9393] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector. OBJECTIVE To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons. EVIDENCE REVIEW The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda. FINDINGS Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy. CONCLUSIONS AND RELEVANCE The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.
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Affiliation(s)
- Eric Goralnick
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Chibuike Ezeibe
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin McCarty
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Juan P Herrera-Escobar
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tomas Andriotti
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elzerie de Jager
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Craig Goolsby
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland
- National Center for Disaster Medicine and Public Health, Rockville, Maryland
| | - Richard Hunt
- National Health Care Preparedness Program, Department of Health and Human Services, Washington, DC
| | - Joel S Weissman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Office of the Dean, Medical School, Aga Khan University, Karachi, Pakistan
| | - Lenworth Jacobs
- Department of Surgery, Hartford Hospital, Hartford, Connecticut
| | | | - Erin Andrade
- Department of Surgery, Washington University in St Louis, Missouri
| | - Jeremy Brown
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC
| | | | - Frank K Butler
- Defense Health Agency, Joint Trauma System, Joint Base San Antonio-Fort Sam Houston, Texas
| | - David Callaway
- Department of Emergency Medicine, Carolinas Medical Center, Atrium Health, Charlotte, North Carolina
| | - Edward J Caterson
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Niteesh K Choudhry
- Center for Healthcare Delivery Sciences, Harvard Medical School, Boston, Massachusetts
| | - Michael R Davis
- Combat Casualty Care Research Program Army Medical Research and Materiel Command, Fort Detrick, Maryland
| | - Alex Eastman
- Countering Weapons of Mass Destruction Office Department of Homeland Security, Washington, DC
| | - Brian J Eastridge
- Department of Surgery, The University of Texas Health Science Center at San Antonio
| | - Jonathan L Epstein
- Training Services Division, American Red Cross, American Red Cross, Washington, DC
| | - Conor L Evans
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston
| | - Marianne Gausche-Hill
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance
| | - Mark L Gestring
- Department of Surgery, Rochester Medical Center, Rochester, New York
| | - Scott A Goldberg
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dan Hanfling
- Forum on Medical and Public Health Preparedness for Catastrophic Events, National Academies of Science, Washington, DC
| | | | - Carl-Oscar Jonson
- Center for Disaster Medicine and Traumatology, Linköping University, Linköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - David R King
- Department of Surgery, Massachusetts General Hospital, Boston
| | - Sean Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Russ S Kotwal
- Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas
| | - Jon R Krohmer
- Office of Emergency Medical Services, National Highway Traffic Safety Administration, Washington, DC
| | - Nomi Levy-Carrick
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
| | - Matthew Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - David P Mooney
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Habeeba Park
- Department of Surgery, University of Maryland Shock Trauma Center, Baltimore
| | - Peter T Pons
- Department of Emergency Medicine, University of Colorado School of Medicine, Denver
| | - Erik Prytz
- Department of Computer and Information Science, Linköping University, Linköping, Sweden
| | - Todd E Rasmussen
- Department of Surgery, F. Edward Hébert School of Medicine Uniformed Services University, Bethesda, Maryland
| | - Michael A Remley
- Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas
| | - Robert Riviello
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ali Salim
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stacy Shackelfold
- Joint Trauma System, Defense Health Agency Combat Support, San Antonio, Texas
| | - E Reed Smith
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, DC
| | - Ronald M Stewart
- Department of Surgery, The University of Texas Health Science Center at San Antonio
| | - Mamta Swaroop
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kevin Ward
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Biomedical Engineering, University of Michigan, Ann Arbor
| | | | - Molly P Jarman
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gezzer Ortega
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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