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Sperry JL, Guyette FX, Rosario-Rivera BL, Kutcher ME, Kornblith LZ, Cotton BA, Wilson CT, Inaba K, Zadorozny EV, Vincent LE, Harner AM, Love ET, Doherty JE, Cuschieri J, Kornblith AE, Fox EE, Bai Y, Hoffman MK, Seger CP, Hudgins J, Mallett-Smith S, Neal MD, Leeper CM, Spinella PC, Yazer MH, Wisniewski SR. Early Cold Stored Platelet Transfusion Following Severe Injury: A Randomized Clinical Trial. Ann Surg 2024; 280:00000658-990000000-00865. [PMID: 38708880 PMCID: PMC11224567 DOI: 10.1097/sla.0000000000006317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
OBJECTIVE To determine the feasibility, efficacy, and safety of early cold stored platelet transfusion compared to standard care resuscitation in patients with hemorrhagic shock. SUMMARY BACKGROUND DATA Data demonstrating the safety and efficacy of early cold stored platelet transfusion are lacking following severe injury. METHODS A phase 2, multicenter, randomized, open label, clinical trial was performed at five U.S. trauma centers. Injured patients at risk of large volume blood transfusion and the need for hemorrhage control procedures were enrolled and randomized. The intervention was the early transfusion of a single apheresis cold stored platelet unit, stored for up to 14 days vs. standard care resuscitation. The primary outcome was feasibility and the principal clinical outcome for efficacy and safety was 24-hour mortality. RESULTS Mortality at 24 hours was 5.9% in patients who were randomized to early cold stored platelet transfusion compared to 10.2% in the standard care arm (difference, -4.3%; 95% CI, -12.8% to 3.5%; P=0.26). No significant differences were found for any of the prespecified ancillary outcomes. Rates of arterial and/or venous thromboembolism and adverse events did not differ across treatment groups. CONCLUSIONS AND RELEVANCE In severely injured patients, early cold stored platelet transfusion is feasible, safe and did not result in a significant lower rate of 24-hour mortality. Early cold stored platelet transfusion did not result in a higher incidence of arterial and/or venous thrombotic complications or adverse events. The storage age of the cold stored platelet product was not associated with significant outcome differences.
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Affiliation(s)
- Jason L. Sperry
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Francis X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Matthew E. Kutcher
- Department of Surgery, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA
| | | | - Bryan A. Cotton
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Chad T. Wilson
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Eva V. Zadorozny
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Emily T. Love
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Joseph E. Doherty
- Department of Surgery, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA
| | | | - Aaron E. Kornblith
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA
| | - Erin E. Fox
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Yu Bai
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | | | | | - Jay Hudgins
- Department of Surgery, University of Southern California, Los Angeles, CA
| | | | - Matthew D. Neal
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Christine M. Leeper
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Philip C. Spinella
- Department of Surgery, Trauma and Transfusion Medicine Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Mark H. Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
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Marsden M, Lendrum R, Davenport R. Revisiting the promise, practice and progress of resuscitative endovascular balloon occlusion of the aorta. Curr Opin Crit Care 2023; 29:689-695. [PMID: 37861182 DOI: 10.1097/mcc.0000000000001106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to temporarily control bleeding and improve central perfusion in critically injured trauma patients remains a controversial topic. In the last decade, select trauma services around the world have gained experience with REBOA. We discuss the recent observational data together with the initial results of the first randomized control trial and provide a view on the next steps for REBOA in trauma resuscitation. RECENT FINDINGS While the observational data continue to be conflicting, the first randomized control trial signals that in the UK, in-hospital REBOA is associated with harm. Likely a result of delays to haemorrhage control, views are again split on whether to abandon complex interventions in bleeding trauma patients and to only prioritize transfer to the operating room or to push REBOA earlier into the post injury phase, recognizing that some patients will not survive without intervention. SUMMARY Better understanding of cardiac shock physiology provides a new lens in which to evaluate REBOA through. Patient selection remains a huge challenge. Invasive blood pressure monitoring, combined with machine learning aided decision support may assist clinicians and their patients in the future. The use of REBOA should not delay definitive haemorrhage control in those patients without impending cardiac arrest.
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Affiliation(s)
- Max Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- Academic Department of Military Surgery and Trauma, Research and Clinical Innovation, Birmingham
| | - Robert Lendrum
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- London's Air Ambulance
- Department of Perioperative Medicine, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
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Biedrzycki CD, Bergmann HP, Remick KN, Qasim Z, Baker JB. Brief Comparative Analysis of Trauma Care Specialties in Europe and the United States. Mil Med 2023; 188:305-309. [PMID: 37208313 DOI: 10.1093/milmed/usad164] [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: 02/07/2023] [Revised: 04/18/2023] [Accepted: 04/28/2023] [Indexed: 05/21/2023] Open
Abstract
Understanding the variation in training and nuances of trauma provider practice between the countries in Europe and the United States is a daunting task. This article briefly reviews the key specialties of trauma care in Europe including emergency medical services (EMS), emergency medicine, anesthesia, trauma surgery, and critical care. The authors hope to inform U.S. military clinicians and medical planners of the major differences in emergency and trauma care that exist across Europe. Emergency medicine exists as both a primary specialty and a subspecialty across Europe, with varying stages of development as a specialty in each country. There is heavy physician involvement in EMS in much of Europe, with anesthesiologists having additional EMS training typically providing prehospital critical care. Because of the historical predominance of blunt trauma in Europe, in many countries, trauma surgery is a subspecialty with initial orthopedic surgery training versus general surgery. Intensive care medicine has various training pathways across Europe, but there have been great advances in standardizing competency requirements across the European Union. Finally, the authors suggest some strategies to mitigate the potential negative consequences of joint medical teams and how to leverage some key differences to advance life-saving medical interoperability across the North Atlantic Treaty Organization alliance.
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Affiliation(s)
- Christopher D Biedrzycki
- Department of Emergency Medicine, Christiana Care, Doctors for Emergency Services, Newark, DE 19718, USA
| | - Harald P Bergmann
- Department of Emergency Medicine, Bundeswehr Central Hospital, Koblenz 56072, Germany
| | - Kyle N Remick
- Department of Surgery, Uniformed Services University School of Medicine, Bethesda, MD 20814, USA
| | - Zaffer Qasim
- Department of Emergency Medicine, University of Pennsylvania Health System, Penn Presbyterian Medical Center, Philadelphia, PA 19104, USA
| | - Jay B Baker
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio Fort Sam Houston, TX 78234, USA
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Chien CY, Lewis MR, Dilday J, Biswas S, Luo Y, Demetriades D. Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study. Am J Surg 2023; 225:414-419. [PMID: 36253317 DOI: 10.1016/j.amjsurg.2022.09.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures. METHODS Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications. RESULTS 93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism. CONCLUSIONS REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism.
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Affiliation(s)
- Chih-Ying Chien
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States; Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Meghan R Lewis
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Joshua Dilday
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Subarna Biswas
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Yong Luo
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States; Trauma Center & Critical Care Medicine, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States.
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Qasim Z. Resuscitative Endovascular Balloon Occlusion of the Aorta. Emerg Med Clin North Am 2023; 41:71-88. [DOI: 10.1016/j.emc.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Dobson GP, Morris JL, Letson HL. Why are bleeding trauma patients still dying? Towards a systems hypothesis of trauma. Front Physiol 2022; 13:990903. [PMID: 36148305 PMCID: PMC9485567 DOI: 10.3389/fphys.2022.990903] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022] Open
Abstract
Over the years, many explanations have been put forward to explain early and late deaths following hemorrhagic trauma. Most include single-event, sequential contributions from sympathetic hyperactivity, endotheliopathy, trauma-induced coagulopathy (TIC), hyperinflammation, immune dysfunction, ATP deficit and multiple organ failure (MOF). We view early and late deaths as a systems failure, not as a series of manifestations that occur over time. The traditional approach appears to be a by-product of last century’s highly reductionist, single-nodal thinking, which also extends to patient management, drug treatment and drug design. Current practices appear to focus more on alleviating symptoms rather than addressing the underlying problem. In this review, we discuss the importance of the system, and focus on the brain’s “privilege” status to control secondary injury processes. Loss of status from blood brain barrier damage may be responsible for poor outcomes. We present a unified Systems Hypothesis Of Trauma (SHOT) which involves: 1) CNS-cardiovascular coupling, 2) Endothelial-glycocalyx health, and 3) Mitochondrial integrity. If central control of cardiovascular coupling is maintained, we hypothesize that the endothelium will be protected, mitochondrial energetics will be maintained, and immune dysregulation, inflammation, TIC and MOF will be minimized. Another overlooked contributor to early and late deaths following hemorrhagic trauma is from the trauma of emergent surgery itself. This adds further stress to central control of secondary injury processes. New point-of-care drug therapies are required to switch the body’s genomic and proteomic programs from an injury phenotype to a survival phenotype. Currently, no drug therapy exists that targets the whole system following major trauma.
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Dobson GP, Morris JL, Letson HL. Immune dysfunction following severe trauma: A systems failure from the central nervous system to mitochondria. Front Med (Lausanne) 2022; 9:968453. [PMID: 36111108 PMCID: PMC9468749 DOI: 10.3389/fmed.2022.968453] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/01/2022] [Indexed: 12/20/2022] Open
Abstract
When a traumatic injury exceeds the body's internal tolerances, the innate immune and inflammatory systems are rapidly activated, and if not contained early, increase morbidity and mortality. Early deaths after hospital admission are mostly from central nervous system (CNS) trauma, hemorrhage and circulatory collapse (30%), and later deaths from hyperinflammation, immunosuppression, infection, sepsis, acute respiratory distress, and multiple organ failure (20%). The molecular drivers of secondary injury include damage associated molecular patterns (DAMPs), pathogen associated molecular patterns (PAMPs) and other immune-modifying agents that activate the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic stress response. Despite a number of drugs targeting specific anti-inflammatory and immune pathways showing promise in animal models, the majority have failed to translate. Reasons for failure include difficulty to replicate the heterogeneity of humans, poorly designed trials, inappropriate use of specific pathogen-free (SPF) animals, ignoring sex-specific differences, and the flawed practice of single-nodal targeting. Systems interconnectedness is a major overlooked factor. We argue that if the CNS is protected early after major trauma and control of cardiovascular function is maintained, the endothelial-glycocalyx will be protected, sufficient oxygen will be delivered, mitochondrial energetics will be maintained, inflammation will be resolved and immune dysfunction will be minimized. The current challenge is to develop new systems-based drugs that target the CNS coupling of whole-body function.
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Affiliation(s)
- Geoffrey P. Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Percutaneous delivery of self-propelling thrombin-containing powder increases survival from non-compressible truncal hemorrhage in a swine model of coagulopathy and hypothermia. J Trauma Acute Care Surg 2022; 93:S86-S93. [PMID: 35545803 DOI: 10.1097/ta.0000000000003670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Non-compressible truncal hemorrhage (NCTH) remains a leading cause of preventable death on the battlefield. Definitively managing severe NCTH requires surgery within the first hour after injury, which is difficult when evacuating casualties from remote and austere environments. During delays to surgery, hemostatic interventions that are performed prehospital can prevent coagulopathy and hemorrhagic shock and increase the likelihood that casualties survive to receive definitive care. We previously reported that a self-propelling thrombin-containing powder (SPTP) can be delivered percutaneously into the abdomen as a minimally invasive intervention and can self-disperse through pooled blood to deliver the hemostatic agents thrombin and tranexamic acid (TXA) locally to noncompressible intracavitary wounds. We hypothesized that in swine with massive NCTH, dilutional coagulopathy and hypothermia, delivering SPTP could extend survival times. METHODS Ten swine (n = 5 per group) underwent NCTH from a Grade V liver injury following a midline laparotomy. The laparotomy was closed with sutures afterwards, creating a hemoperitoneum, and animals were managed with crystalloid fluid resuscitation, or crystalloid resuscitation and SPTP. SPTP was delivered into the closed abdomen using a CO2-powered spray device and a catheter placed into the hemoperitoneum, entering through the upper right quadrant using the Seldinger technique. Survival to one and three hours was recorded. In an additional animal, hemorrhage was created laparoscopically and SPTP was imaged in-situ within the abdomen to visually track dispersion of the particles. RESULTS SPTP dispersed as far as 35 +/- 5.0 cm within the abdomen. SPTP increased survival to one and three hours (Kaplan-Meier p = 0.007 for both). The median survival time was 61 minutes with SPTP and 31 minutes without (p = 0.016). CONCLUSION SPTP effectively disperses medications throughout a hemoperitoneum and increases survival in a model of NCTH. SPTP is a promising strategy for nonsurgical management of NCTH, warranting further testing of its safety and efficacy. LEVEL OF EVIDENCE Basic Science, N/A.
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Duchesne J, Slaughter K, Puente I, Berne JD, Yorkgitis B, Mull J, Sperry J, Tessmer M, Costantini T, Berndtson AE, Kai T, Rokvic G, Norwood S, Meadows K, Chang G, Lemon BM, Jacome T, Van Sant L, Paul J, Maher Z, Goldberg AJ, Madayag RM, Pinson G, Lieser MJ, Haan J, Marshall G, Carrick M, Tatum D. Impact of time to surgery on mortality in hypotensive patients with noncompressible torso hemorrhage: An AAST multicenter, prospective study. J Trauma Acute Care Surg 2022; 92:801-811. [PMID: 35468112 DOI: 10.1097/ta.0000000000003544] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Death from noncompressible torso hemorrhage (NCTH) may be preventable with improved prehospital care and shorter in-hospital times to hemorrhage control. We hypothesized that shorter times to surgical intervention for hemorrhage control would decrease mortality in hypotensive patients with NCTH. METHODS This was an AAST-sponsored multicenter, prospective analysis of hypotensive patients aged 15+ years who presented with NCTH from May 2018 to December 2020. Hypotension was defined as an initial systolic blood pressure (SBP) ≤ 90 mm Hg. Primary outcomes of interest were time to surgical intervention and in-hospital mortality. RESULTS There were 242 hypotensive patients, of which 48 died (19.8%). Nonsurvivors had higher mean age (47.3 vs. 38.8; p = 0.02), higher mean New Injury Severity Score (38 vs. 29; p < 0.001), lower admit systolic blood pressure (68 vs. 79 mm Hg; p < 0.01), higher incidence of vascular injury (41.7% vs. 21.1%; p = 0.02), and shorter median (interquartile range, 25-75) time from injury to operating room start (74 minutes [48-98 minutes] vs. 88 minutes [61-128 minutes]; p = 0.03) than did survivors. Multivariable Cox regression showed shorter time from emergency department arrival to operating room start was not associated with improved survival (p = 0.04). CONCLUSION Patients who died arrived to a trauma center in a similar time frame as did survivors but presented in greater physiological distress and had significantly shorter times to surgical hemorrhage intervention than did survivors. This suggests that even expediting a critically ill patient through the current trauma system is not sufficient time to save lives from NCTH. Civilian prehospital advance resuscitative care starting from the patient first contact needs special consideration. LEVEL OF EVIDENCE Prognostic/Epidemiologic, Level III.
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Affiliation(s)
- Juan Duchesne
- From the Tulane University School of Medicine (J.D., K.S., D.T.), New Orleans, Louisiana; Broward Health Medical Center (I.P., J.D.B.), Fort Lauderdale; University of Florida-Jacksonville (B.Y., J.M.), Jacksonville, Florida; University of Pittsburgh (J.S., M.T.), Pittsburgh, Pennsylvania; UC San Diego Medical Center (T.C., A.E.B.), San Diego, California; University of Kentucky Chandler Medical Center (T.K., G.R.), Lexington, Kentucky; University of Texas Health Tyler (S.N., K.M.), Tyler, Texas; Mount Sinai Hospital (G.C., B.M.L.), Chicago, Illinois; Our Lady of the Lake Regional Medical Center (T.J.), Baton Rouge, Louisiana; University of New Mexico Hospital (L.V.S., J.P.), Albuquerque, New Mexico; Temple University Hospital (Z.M., A.J.G.), Philadelphia, Pennsylvania; St. Anthony Hospital (R.M.M., G.P.), Lakewood, Colorado; Research Medical Center (M.J.L.), Kansas City, Missouri; Ascension Via Christi Hospital St. Francis (J.H.), Wichita, Kansas; and Medical City Plano (G.M., M.C.), Plano, Texas
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