Transfusion strategy in multiple trauma patients:

Effects of Targeted Intervention plus Comprehensive Nursing on the Quality of Life and Nursing Satisfaction in Multiple Traumas

Objective

To explore the effect of targeted intervention plus comprehensive nursing on quality of life and nursing satisfaction of patients with multiple traumas.

Methods

Totally 68 cases with multiple traumas admitted to Xishan People's Hospital from September 2018 to September 2019 were recruited and randomized into a control group and a study group via the random number table method, with 34 cases in each group. The control group received conventional nursing, and the study group adopted targeted intervention plus comprehensive nursing.

Results

The study group showed significantly lower life scores and Hospital Anxiety and Depression Scale (HADS) scores after the intervention, as compared to the control group. The average Newcastle Nursing Service Satisfaction Scale (NSNS) scores, various self-care ability scores, and comprehensive self-care ability scores were higher than those of the control group. Significantly lower Numerical Rating Scale (NRS) scores were observed in the study group at 7 d and 10 d of intervention than those of the control group.

Conclusion

Targeted intervention plus comprehensive nursing enhances the quality of life of patients and nursing satisfaction, which merits clinical promotion.

Terrorist incidents: strategic treatment objectives, tactical diagnostic procedures and the estimated need of blood and clotting products

BACKGROUND

Terrorism-related incidents that are associated with mass casualties (mass-casualty terrorist incidents) are a medical and organisational challenge for every hospital because of the special injury patterns involved, the time of the incident, the development of the situation, the initial lack of information, the number of injured, and the number of uninjured survivors who self-refer to a hospital.

METHODS

The Terror and Disaster Surgical Care (TDSC®) - Course was developed in order to address mass-casualty terrorist incidents and to provide surgeons with the specialist medical and surgical knowledge and skills required for these special situations. The focus of the TDSC® course is on how to provide surgical care and how to deploy scarce resources in a particular tactical situation in such a way that the number of survivors is maximised.

RESULTS

The effective management of such a tactical situation must be based on priorities and first and foremost requires the standardised sorting and categorisation of the injured at the hospital. The aim of triage, or the sorting of the injured, is to immediately identify patients with life-threatening injuries in environments with strained resources. The medical management of mass-casualty terrorist incidents requires tactical abbreviated surgical care (TASC) teams that have the skills needed to perform a primary survey and to provide care for casualties who need immediate surgery (triage category 1-T1). Initial fluid therapy should be restrictive (permissive hypotension) unless contraindicated. Clotting products are replaced in a standardised manner on the basis of patient requirements, which are calculated using rapidly available surrogates (blood gas analysis). Blood products can be administered or kept available depending on risks and triage categories. The highest priority should be given to the identification and management of haemodynamically unstable patients who require immediate surgery for injuries associated with bleeding into body cavities (T1 + +).

CONCLUSION

The recommendations and approaches described here should be considered as proposals for hospitals to develop standards or modify well-established standards that enable them to prepare themselves successfully for situations (e.g. mass-casualty terrorist or shooter incidents) in which their resources are temporarily overwhelmed.

[ATLS® and TDSC®: how it fits together : A treatment concept for mass casualty and terrorist-related mass casualty situations, life-threatening and special scenarios]

Terrorist-related mass casualty incidents represent a medical and organizational challenge for all hospitals. The main reasons are the special patterns of injuries, the onset and development of the scenario, the lack of information at the beginning, the overall number of casualties and the number of uninjured but involved patients presenting at the hospital.Due to these circumstances and the high percentage of penetrating injuries with a permanent risk of uncontrollable bleeding and other life-threatening complications, a strategic and tactical initial surgical care is necessary.For these special terrorist-related mass casualty (MasCal) situations, the Terror and Disaster Surgical Care (TDSC®) course was developed and imparts special medical and surgical knowledge as well as a scenario-based training in surgical decision-making. The TDSC® course focusses on the scenario-related provision of surgical care and distribution of the limited resources to enable survival for as many patients as possible.To improve individualized trauma care course formats, such as the Advanced Trauma Life Support (ATLS®) were established and are nowadays widespread in Germany. It could be shown that standardized approaches and algorithm-based treatment could improve the outcome of trauma victims. Faced with the present day permanent risk of a possible terrorist-related MasCal situation, the question arises how and to what extent elements and principles of both course formats (TDSC® and ATLS®) could be used to improve and organize the initial care in a terrorist-linked MasCal incident.For the first time it is shown that the key elements of both courses (primary survey of the ATLS® and the TDSC® principles: categorization, prioritization, disposition and realization) could be established and integratively used to structure the initial intrahospital medical and surgical care.

Comparison of two different coagulation algorithms on the use of allogenic blood products and coagulation factors in severely injured trauma patients: a retrospective, multicentre, observational study

Background

At the University Hospital Zurich (USZ) and the Cantonal Hospital of Lucerne (LUKS) an individualized goal-directed coagulation and transfusion algorithm was introduced and implemented before 2012 (Coagulation algorithm of the USZ: USZ-Alg; of the LUKS: LUKS-Alg). Main differences between both algorithms are: 1) A target haematocrit-range of 0.21–0.24 (USZ-Alg) vs. a lower haematocrit limit only (LUKS-Alg). 2) Blind coagulation-package in selected cases (LUKS-Alg only). 3) Factor XIII substitution is considered earlier according to the USZ-Alg.

The Aim of this study was to analyse the impact of two different coagulation algorithms on the administration of allogeneic blood products, coagulation factors, the frequency of point of care measurements and haemoglobin level during resuscitation in trauma patients.

Methods

This retrospective, multicentre, observational study included all adult trauma patients with an injury severity score (ISS) ≥ 16 primarily admitted to the USZ or the LUKS in the period of 2012 to 2014. Referred patients and patients with missing/incomplete records of the initial treatment at the emergency department (ED) were excluded. Two propensity score matched groups were created using a non-parsimonious logistic regression to account for potential differences in patient and trauma epidemiology.

Results

A total of 632 patients meeting the inclusion criteria were admitted to the two hospitals: 428 to the USZ and 204 to the LUKS. Two Propensity score matched groups (n = 172 per group) were created. Treatment with USZ-Alg compared with LUKS-Alg resulted in a lower number of patients receiving RBC transfusion (11.6% vs. 29.7%, OR 3.2, 95% CI 1.8–5.7, p < 0.001) and lower amount of RBC transfusion (0.5 SD 1.9 vs. 1.5 SD 3.9, p < 0.001). The different treatment algorithms resulted in lower mean haemoglobin levels in the USZ during resuscitation (8.0 SD 1.7 vs. 9.4 SD 1.8 g/dl, p < 0.001) and at admission to the ICU (8.3 SD 1.2 vs. 10.6 SD 1.9 g/dl, p < 0.001. Blood gas analyses to monitor treatment and haematocrit were made more frequently in the USZ (1.4 SD 0.8 vs. 1.0 SD 0.7 measurements per hour, p = 0.004).

Conclusion

A goal-directed coagulation algorithm including a target haematocrit-range including frequent and repeated haematocrit measurement may lead to less transfusion of RBC compared to only a lower haematocrit limit, when treating severely traumatized patients.

Electronic supplementary material

The online version of this article (10.1186/s13049-017-0463-0) contains supplementary material, which is available to authorized users.

Targeted Thromboelastographic (TEG) Blood Component and Pharmacologic Hemostatic Therapy in Traumatic and Acquired Coagulopathy

Trauma-induced coagulopathy (TIC) is a recently described condition which traditionally has been diagnosed by the common coagulation tests (CCTs) such as prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), platelet count, and fibrinogen levels. The varying sensitivity and specificity of these CCTs have led trauma coagulation researchers and clinicians to use Viscoelastic Tests (VET) such as Thromboelastography (TEG) to provide Targeted Thromboelastographic Hemostatic and Adjunctive Therapy (TTHAT) in a goal directed fashion to those trauma patients in need of hemostatic resuscitation. This review describes the utility of VETs, in particular, TEG, to provide TTHAT in trauma and acquired non-trauma-induced coagulopathy.

Targeted Coagulation Management in Severe Trauma: The Controversies and the Evidence

Hemorrhage in the setting of severe trauma is a leading cause of death worldwide. The pathophysiology of hemorrhage and coagulopathy in severe trauma is complex and remains poorly understood. Most clinicians currently treating trauma patients acknowledge the presence of a coagulopathy unique to trauma patients-trauma-induced coagulopathy (TIC)-independently associated with increased mortality. The complexity and incomplete understanding of TIC has resulted in significant controversy regarding optimum management. Although the majority of trauma centers utilize fixed-ratio massive transfusion protocols in severe traumatic hemorrhage, a widely accepted "ideal" transfusion ratio of blood to blood products remains elusive. The recent use of viscoelastic hemostatic assays (VHAs) to guide blood product replacement has further provoked debate as to the optimum transfusion strategy. The use of VHA to quantify the functional contributions of individual components of the coagulation system may permit targeted treatment of TIC but remains controversial and is unlikely to demonstrate a mortality benefit in light of the heterogeneity of the trauma population. Thus, VHA-guided algorithms as an alternative to fixed product ratios in trauma are not universally accepted, and a hybrid strategy starting with fixed-ratio transfusion and incorporating VHA data as they become available is favored by some institutions. We review the current evidence for the management of coagulopathy in trauma, the rationale behind the use of targeted and fixed-ratio approaches and explore future directions.

Blood Component Therapy and Coagulopathy in Trauma: A Systematic Review of the Literature from the Trauma Update Group

Background

Traumatic coagulopathy is thought to increase mortality and its treatment to reduce preventable deaths. However, there is still uncertainty in this field, and available literature results may have been overestimated.

Methods

We searched the MEDLINE database using the PubMed platform. We formulated four queries investigating the prognostic weight of traumatic coagulopathy defined according to conventional laboratory testing, and the effectiveness in reducing mortality of three different treatments aimed at contrasting coagulopathy (high fresh frozen plasma/packed red blood cells ratios, fibrinogen, and tranexamic acid administration). Randomized controlled trials were selected along with observational studies that used a multivariable approach to adjust for confounding. Strict criteria were adopted for quality assessment based on a two-step approach. First, we rated quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Then, this rating was downgraded if other three criteria were not met: high reporting quality according to shared standards, absence of internal methodological and statistical issues not detailed by the GRADE system, and absence of external validity issues.

Results

With few exceptions, the GRADE rating, reporting and methodological quality of observational studies was “very low”, with frequent external validity issues. The only two randomized trials retrieved were, instead, of high quality. Only weak evidence was found for a relation between coagulopathy and mortality. Very weak evidence was found supporting the use of fibrinogen administration to reduce mortality in trauma. On the other hand, we found high evidence that the use of 1:1 vs. 1:2 high fresh frozen plasma/packed red blood cells ratios failed to obtain a 12% mortality reduction. This does not exclude lower mortality rates, which have not been investigated. The use of tranexamic acid in trauma was supported by “high” quality evidence according to the GRADE classification but was downgraded to “moderate” for external validity issues.

Conclusions

Tranexamic acid is effective in reducing mortality in trauma. The other transfusion practices we investigated have been inadequately studied in the literature, as well as the independent association between mortality and coagulopathy measured with traditional laboratory testing. Overall, in this field of research literature quality is poor.

Are the paradigms in trauma disease changing?

Despite an annual trauma mortality of 5 million people worldwide, resulting in countless physical disabilities and enormous expenses, there are no standardized guidelines on trauma organization and management. Over the last few decades there have been very notorious improvements in severe trauma care, though organizational and economical aspects such as research funding still need to be better engineered. Indeed, trauma lags behind other serious diseases in terms of research and organization. The rapid developments in trauma care have produced original models available for research projects, initial resuscitation protocols and radiological procedures such as CT for the initial management of trauma patients, among other advances. This progress underscores the need for a multidisciplinary approach to the initial management and follow-up of this complicated patient population, where intensivists play a major role in both the patient admission and subsequent care at the trauma unit.

Point of care and factor concentrate-based coagulation algorithms

In the last years it has become evident that the use of blood products should be reduced whenever possible. There is increasing evidence regarding serious adverse events, including higher mortality and morbidity, related to transfusions. The use of point of care (POC) devices integrated in algorithms is one of the important mechanisms to limit blood product exposure. Any type of algorithm, especially the POC-based ones, allows goal-directed transfusions of blood products and even better targeted factor concentrate substitutions. Different types of algorithms in different surgical settings (cardiac surgery, trauma, liver surgery etc.) have been established with growing interest in their use as they offer objective therapy for management and reduction of blood product use. The use of POC devices with evidence-based algorithms is important in the bleeding patient independent of its origin (traumatic vs. surgical). The use of factor concentrates compared to the classical blood products can be cost-saving, beneficial for the patient, and in agreement with the WHO-requested standard of care. The empiric and uncontrolled use of blood products such as fresh frozen plasma, red blood cells, and platelets without POC monitoring should no longer be followed with regard to actual evidence in literature. Furthermore, the use of factor concentrates may provide better outcomes and potential for cost saving.