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Mould-Millman NK, Dixon J, Beaty BL, Suresh K, de Vries S, Bester B, Moreira F, Cunningham C, Moodley K, Cermak R, Schauer SG, Maddry JK, Bills CB, Havranek EP, Bebarta VS, Ginde AA. Improving prehospital traumatic shock care: implementation and clinical effectiveness of a pragmatic, quasi-experimental trial in a resource-constrained South African setting. BMJ Open 2023; 13:e060338. [PMID: 37185181 PMCID: PMC10151988 DOI: 10.1136/bmjopen-2021-060338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVES This project seeks to improve providers' practices and patient outcomes from prehospital (ie, ambulance-based) trauma care in a middle-income country using a novel implementation strategy to introduce a bundled clinical intervention. DESIGN We conduct a two-arm, controlled, mixed-methods, hybrid type II study. SETTING This study was conducted in the Western Cape Government Emergency Medical Services (EMS) system of South Africa. INTERVENTIONS We pragmatically implemented a simplified prehospital bundle of trauma care (with five core elements) using a novel workplace-based, peer-to-peer, rapid training format. We assigned the intervention and control sites. OUTCOME MEASURES We assessed implementation effectiveness among EMS providers and stakeholders, using the RE-AIM framework. Clinical effectiveness was assessed at the patient level, using changes in Shock Index x Age (SIxAge). Indices and cut-offs were established a priori. We performed a difference-in-differences (D-I-D) analysis with a multivariable mixed effects model. RESULTS 198 of 240 (82.5%) EMS providers participated, 93 (47%) intervention and 105 (53%) control, with similar baseline characteristics. The overall implementation effectiveness was excellent (80.6%): reach was good (65%), effectiveness was excellent (87%), implementation fidelity was good (72%) and adoption was excellent (87%). Participants and stakeholders generally reported very high satisfaction with the implementation strategy citing that it was a strong operational fit and effective educational model for their organisation. A total of 770 patients were included: 329 (42.7%) interventions and 441 (57.3%) controls, with no baseline differences. Intervention arm patients had more improved SIxAge compared with control at 4 months, which was not statistically significant (-1.4 D-I-D; p=0.35). There was no significant difference in change of SIxAge over time between the groups for any of the other time intervals (p=0.99). CONCLUSIONS In this quasi-experimental trial of bundled care using the novel workplace rapid training approach, we found overall excellent implementation effectiveness but no overall statistically significant clinical effectiveness.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Julia Dixon
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Krithika Suresh
- Department of Biostatistics & Informatics, University of Colorado School of Public Health, Aurora, Colorado, USA
| | - Shaheem de Vries
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Beatrix Bester
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Fabio Moreira
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Charmaine Cunningham
- Division of Emergency Medicine, University of Cape Town Faculty of Health Sciences, Belville, South Africa
| | - Kubendhren Moodley
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Radomir Cermak
- Emergency Medical Services, Western Cape Government Department of Health, City of Cape Town, South Africa
| | - Steven G Schauer
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USA
| | - Joseph K Maddry
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, Texas, USA
| | - Corey B Bills
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Edward P Havranek
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
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Simovic MO, Yang Z, Jordan BS, Fraker TL, Cancio TS, Lucas ML, Cancio LC, Li Y. Immunopathological Alterations after Blast Injury and Hemorrhage in a Swine Model of Prolonged Damage Control Resuscitation. Int J Mol Sci 2023; 24:ijms24087494. [PMID: 37108656 PMCID: PMC10139120 DOI: 10.3390/ijms24087494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Trauma-related hemorrhagic shock (HS) remains a leading cause of death among military and civilian trauma patients. We have previously shown that administration of complement and HMGB1 inhibitors attenuate morbidity and mortality 24 h after injury in a rat model of blast injury (BI) and HS. To further validate these results, this study aimed to develop a swine model and evaluate BI+HS-induced pathophysiology. Anesthetized Yucatan minipigs underwent combined BI and volume-controlled hemorrhage. After 30 min of shock, animals received an intravenous bolus of PlasmaLyte A and a continuous PlasmaLyte A infusion. The survival rate was 80% (4/5), and the non-survivor expired 72 min post-BI. Circulating organ-functional biomarkers, inflammatory biomarkers, histopathological evaluation, and CT scans indicated evidence of multiple-organ damage, systemic innate immunological activation, and local tissue inflammation in the injured animals. Interestingly, a rapid and dramatic increase in plasma levels of HMGB1 and C3a and markedly early myocarditis and encephalitis were associated with early death post-BI+HS. This study suggests that this model reflects the immunopathological alterations of polytrauma in humans during shock and prolonged damage control resuscitation. This experimental protocol could be helpful in the assessment of immunological damage control resuscitation approaches during the prolonged care of warfighters.
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Affiliation(s)
- Milomir O Simovic
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
| | - Zhangsheng Yang
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Bryan S Jordan
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Tamara L Fraker
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
| | - Tomas S Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Michael L Lucas
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Leopoldo C Cancio
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
| | - Yansong Li
- US Army Institute of Surgical Research, Fort Sam Houston, San Antonio, TX 78234, USA
- The Geneva Foundation, Tacoma, WA 98402, USA
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Chon SB, Lee MJ, Oh WS, Park YJ, Kwon JM, Kim K. A simple and novel equation to estimate the degree of bleeding in haemorrhagic shock: mathematical derivation and preliminary in vivo validation. THE KOREAN JOURNAL OF PHYSIOLOGY & PHARMACOLOGY 2022; 26:195-205. [PMID: 35477547 PMCID: PMC9046898 DOI: 10.4196/kjpp.2022.26.3.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 11/18/2022]
Abstract
Determining blood loss [100% – RBV (%)] is challenging in the management of haemorrhagic shock. We derived an equation estimating RBV (%) via serial haematocrits (Hct1, Hct2) by fixing infused crystalloid fluid volume (N) as [0.015 × body weight (g)]. Then, we validated it in vivo. Mathematically, the following estimation equation was derived: RBV (%) = 24k / [(Hct1 / Hct2) – 1]. For validation, non-ongoing haemorrhagic shock was induced in Sprague–Dawley rats by withdrawing 20.0%–60.0% of their total blood volume (TBV) in 5.0% intervals (n = 9). Hct1 was checked after 10 min and normal saline N cc was infused over 10 min. Hct2 was checked five minutes later. We applied a linear equation to explain RBV (%) with 1 / [(Hct1 / Hct2) – 1]. Seven rats losing 30.0%–60.0% of their TBV suffered shock persistently. For them, RBV (%) was updated as 5.67 / [(Hct1 / Hct2) – 1] + 32.8 (95% confidence interval [CI] of the slope: 3.14–8.21, p = 0.002, R2 = 0.87). On a Bland-Altman plot, the difference between the estimated and actual RBV was 0.00 ± 4.03%; the 95% CIs of the limits of agreements were included within the pre-determined criterion of validation (< 20%). For rats suffering from persistent, non-ongoing haemorrhagic shock, we derived and validated a simple equation estimating RBV (%). This enables the calculation of blood loss via information on serial haematocrits under a fixed N. Clinical validation is required before utilisation for emergency care of haemorrhagic shock.
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Affiliation(s)
- Sung-Bin Chon
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam 13496, Korea
| | - Min Ji Lee
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam 13496, Korea
| | - Won Sup Oh
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon 24289, Korea
| | - Ye Jin Park
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam 13496, Korea
| | - Joon-Myoung Kwon
- Department of Critical Care and Emergency Medicine, Mediplex Sejong Hospital, Incheon 21080, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, CHA Bundang Medical Center, Seongnam 13496, Korea
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Wal A, Khandai M, Vig H, Srivastava P, Agarwal A, Wadhwani S, Wal P. Evidence-Based Treatment, assisted by Mobile Technology to Deliver, and Evidence-Based Drugs in South Asian Countries. ARCHIVES OF PHARMACY PRACTICE 2022. [DOI: 10.51847/d5zeajvk6x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Mayer AR, Dodd AB, Rannou-Latella JG, Stephenson DD, Dodd RJ, Ling JM, Mehos CJ, Robertson-Benta CR, Pabbathi Reddy S, Kinsler RE, Vermillion MS, Gigliotti AP, Sicard V, Lloyd AL, Erhardt EB, Gill JM, Lai C, Guedes VA, Chaudry IH. 17α-Ethinyl estradiol-3-sulfate increases survival and hemodynamic functioning in a large animal model of combined traumatic brain injury and hemorrhagic shock: a randomized control trial. Crit Care 2021; 25:428. [PMID: 34915927 PMCID: PMC8675515 DOI: 10.1186/s13054-021-03844-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/26/2021] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Traumatic brain injury (TBI) and severe blood loss resulting in hemorrhagic shock (HS) represent leading causes of trauma-induced mortality, especially when co-occurring in pre-hospital settings where standard therapies are not readily available. The primary objective of this study was to determine if 17α-ethinyl estradiol-3-sulfate (EE-3-SO4) increases survival, promotes more rapid cardiovascular recovery, or confers neuroprotection relative to Placebo following TBI + HS.
Methods
All methods were approved by required regulatory agencies prior to study initiation. In this fully randomized, blinded preclinical study, eighty (50% females) sexually mature (190.64 ± 21.04 days old; 28.18 ± 2.72 kg) Yucatan swine were used. Sixty-eight animals received a closed-head, accelerative TBI followed by removal of approximately 40% of circulating blood volume. Animals were then intravenously administered EE-3-SO4 formulated in the vehicle at 5.0 mg/mL (dosed at 0.2 mL/kg) or Placebo (0.45% sodium chloride solution) via a continuous pump (0.2 mL/kg over 5 min). Twelve swine were included as uninjured Shams to further characterize model pathology and replicate previous findings. All animals were monitored for up to 5 h in the absence of any other life-saving measures (e.g., mechanical ventilation, fluid resuscitation).
Results
A comparison of Placebo-treated relative to Sham animals indicated evidence of acidosis, decreased arterial pressure, increased heart rate, diffuse axonal injury and blood–brain barrier breach. The percentage of animals surviving to 295 min post-injury was significantly higher for the EE-3-SO4 (28/31; 90.3%) relative to Placebo (24/33; 72.7%) cohort. EE-3-SO4 also restored pulse pressure more rapidly post-drug administration, but did not confer any benefits in terms of shock index. Primary blood-based measurements of neuroinflammation and blood brain breach were also null, whereas secondary measurements of diffuse axonal injury suggested a more rapid return to baseline for the EE-3-SO4 group. Survival status was associated with biological sex (female > male), as well as evidence of increased acidosis and neurotrauma independent of EE-3-SO4 or Placebo administration.
Conclusions
EE-3-SO4 is efficacious in promoting survival and more rapidly restoring cardiovascular homeostasis following polytraumatic injuries in pre-hospital environments (rural and military) in the absence of standard therapies. Poly-therapeutic approaches targeting additional mechanisms (increased hemostasis, oxygen-carrying capacity, etc.) should be considered in future studies.
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Imach S, Wafaisade A, Lefering R, Böhmer A, Schieren M, Suárez V, Fröhlich M. The impact of prehospital tranexamic acid on mortality and transfusion requirements: match-pair analysis from the nationwide German TraumaRegister DGU®. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:277. [PMID: 34348782 PMCID: PMC8336395 DOI: 10.1186/s13054-021-03701-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022]
Abstract
Background Outcome data about the use of tranexamic acid (TXA) in civilian patients in mature trauma systems are scarce. The aim of this study was to determine how severely injured patients are affected by the widespread prehospital use of TXA in Germany. Methods The international TraumaRegister DGU® was retrospectively analyzed for severely injured patients with risk of bleeding (2015 until 2019) treated with at least one dose of TXA in the prehospital phase (TXA group). These were matched with patients who had not received prehospital TXA (control group), applying propensity score-based matching. Adult patients (≥ 16) admitted to a trauma center in Germany with an Injury Severity Score (ISS) ≥ 9 points were included. Results The matching yielded two comparable cohorts (n = 2275 in each group), and the mean ISS was 32.4 ± 14.7 in TXA group vs. 32.0 ± 14.5 in control group (p = 0.378). Around a third in both groups received one dose of TXA after hospital admission. TXA patients were significantly more transfused (p = 0.022), but needed significantly less packed red blood cells (p ≤ 0.001) and fresh frozen plasma (p = 0.023), when transfused. Massive transfusion rate was significantly lower in the TXA group (5.5% versus 7.2%, p = 0.015). Mortality was similar except for early mortality after 6 h (p = 0.004) and 12 h (p = 0.045). Among non-survivors hemorrhage as leading cause of death was less in the TXA group (3.0% vs. 4.3%, p = 0.021). Thromboembolic events were not significantly different between both groups (TXA 6.1%, control 4.9%, p = 0.080). Conclusion This is the largest civilian study in which the effect of prehospital TXA use in a mature trauma system has been examined. TXA use in severely injured patients was associated with a significantly lower risk of massive transfusion and lower mortality in the early in-hospital treatment period. Due to repetitive administration, a dose-dependent effect of TXA must be discussed.
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Affiliation(s)
- Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany.
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Andreas Böhmer
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Mark Schieren
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Victor Suárez
- Department II of Internal Medicine (Nephrology, Rheumatology, Diabetes and General Internal Medicine) and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Matthias Fröhlich
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
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Cap AP, Cannon JW, Reade MC. Synthetic blood and blood products for combat casualty care and beyond. J Trauma Acute Care Surg 2021; 91:S26-S32. [PMID: 34324470 DOI: 10.1097/ta.0000000000003248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ABSTRACT Synthetic biology adopts an engineering design approach to create innovative treatments that are reliable, scalable, and customizable to individual patients. Interest in substitutes for allogenic blood components, primarily red blood cells and platelets, increased in the 1980s because of concerns over infectious disease transmission. However, only now, with emerging synthetic approaches, are such substitutes showing genuine promise. Affordable alternatives to donated blood would be of enormous benefit worldwide. Several approaches to replacing the oxygen-carrying function of red cells are under advanced investigation. Hemoglobin-based oxygen carriers incorporate modifications to reduce the renal toxicity and nitric oxide scavenging of free hemoglobin. While use of earlier-generation hemoglobin-based oxygen carriers may be limited to circumstances in which blood transfusion is not an option, recent advances in chemical modification of hemoglobin may eventually overcome such problems. Another approach encases hemoglobin molecules in biocompatible synthetic nanoparticles. An alternative is the ex vivo production of red cells in bioreactors, with or without genetic manipulation, that offers the potential of a universal donor product. Various strategies to manufacture synthetic platelets are also underway, ranging from simple phospholipid liposomes encapsulating adenosine diphosphate and decorated with fibrinogen fragments, to more complex capsules with multiple receptor peptide sequences. Ex vivo production of platelets in bioreactors is also possible including, for example, platelets derived from induced pluripotent stem cells that are differentiated into a megakaryocytic lineage. Prior to clinical use, trials assessing synthetic blood components must evaluate meaningful safety and effectiveness outcomes in relatively large numbers of critically ill patients. Overcoming these challenges may be as much a hurdle as product design. This article reviews the state of the science of the synthetic biology approach to developing blood component substitutes.
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Affiliation(s)
- Andrew P Cap
- From the US Army Institute of Surgical Research (A.P.C.), For Sam Houston, Texas; Uniformed Services University (A.P.C., J.W.C.), Bethesda, Maryland; Division of Traumatology, Surgical Critical Care & Emergency Surgery (J.W.C.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Joint Health Command (M.C.R.), Australian Defence Force, Canberra; Faculty of Medicine (M.C.R.), University of Queensland, Brisbane; and Royal Brisbane and Women's Hospital (M.C.R.), Brisbane, Australia
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9
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Mayer AR, Dodd AB, Ling JM, Stephenson DD, Rannou-Latella JG, Vermillion MS, Mehos CJ, Johnson VE, Gigliotti AP, Dodd RJ, Chaudry IH, Meier TB, Smith DH, Bragin DE, Lai C, Wagner CL, Guedes VA, Gill JM, Kinsler R. Survival Rates and Biomarkers in a Large Animal Model of Traumatic Brain Injury Combined With Two Different Levels of Blood Loss. Shock 2021; 55:554-562. [PMID: 32881755 PMCID: PMC8112147 DOI: 10.1097/shk.0000000000001653] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The pathology resulting from concurrent traumatic brain injury (TBI) and hemorrhagic shock (HS; TBI+HS) are leading causes of mortality and morbidity worldwide following trauma. However, the majority of large animal models of TBI+HS have utilized focal/contusional injuries rather than incorporating the types of brain trauma (closed-head injury caused by dynamic acceleration) that typify human injury. OBJECTIVE To examine survival rates and effects on biomarkers from rotational TBI with two levels of HS. METHODS Twenty-two sexually mature Yucatan swine (30.39 ± 2.25 kg; 11 females) therefore underwent either Sham trauma procedures (n = 6) or a dynamic acceleration TBI combined with either 55% (n = 8) or 40% (n = 8) blood loss in this serial study. RESULTS Survival rates were significantly higher for the TBI+40% (87.5%) relative to TBI+55% (12.5%) cohort, with the majority of TBI+55% animals expiring within 2 h post-trauma from apnea. Blood-based neural biomarkers and immunohistochemistry indicated evidence of diffuse axonal injury (increased NFL/Aβ42), blood-brain barrier breach (increased immunoglobulin G) and inflammation (increased glial fibrillary acidic protein/ionized calcium-binding adaptor molecule 1) in the injured cohorts relative to Shams. Invasive hemodynamic measurements indicated increased shock index and decreased pulse pressure in both injury cohorts, with evidence of partial recovery for invasive hemodynamic measurements in the TBI+40% cohort. Similarly, although both injury groups demonstrated ionic and blood gas abnormalities immediately postinjury, metabolic acidosis continued to increase in the TBI+55% group ∼85 min postinjury. Somewhat surprisingly, both neural and physiological biomarkers showed significant changes within the Sham cohort across the multi-hour experimental procedure, most likely associated with prolonged anesthesia. CONCLUSION Current results suggest the TBI+55% model may be more appropriate for severe trauma requiring immediate medical attention/standard fluid resuscitation protocols whereas the TBI+40% model may be useful for studies of prolonged field care.
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Affiliation(s)
- Andrew R. Mayer
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, New Mexico
- Neurology Department, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Psychiatry Department, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Psychology Department, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Andrew B. Dodd
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, New Mexico
| | - Josef M. Ling
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, New Mexico
| | - David D. Stephenson
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, New Mexico
| | | | - Meghan S. Vermillion
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, New Mexico
| | - Carissa J. Mehos
- Neurosciences Department, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Victoria E. Johnson
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew P. Gigliotti
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, New Mexico
| | - Rebecca J. Dodd
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, New Mexico
| | - Irshad H. Chaudry
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timothy B. Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Douglas H. Smith
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Denis E. Bragin
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, New Mexico
- Neurosurgery Department, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Chen Lai
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - Chelsea L. Wagner
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - Vivian A. Guedes
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - Jessica M. Gill
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - Rachel Kinsler
- Enroute Care Group, U.S. Army Aeromedical Research Laboratory, Fort Rucker, Alabama
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Wang L, Lou J, Cao J, Wang T, Liu J, Mi W. Bicarbonate Ringer's solution for early resuscitation in hemorrhagic shock rabbits. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:462. [PMID: 33850859 PMCID: PMC8039674 DOI: 10.21037/atm-21-97] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background Fluid resuscitation is important for correcting hypovolemia. Isotonic crystalloids are the preferred solution for the initial clinical management of patients with multiple traumas. Bicarbonated Ringer’s solution (BRS), offering physiological levels of bicarbonate ions and electrolyte ions, can be used for supplementing missing extracellular fluid and correcting metabolic acidosis. We here investigated the effects of BRS on the resuscitation of hemorrhagic shock models and compared the resuscitation performance of three crystalloids, including BRS, acetated Ringer’s solution (ARS), and normal saline. Methods Thirty adult male New Zealand rabbits were randomly divided into five groups (n=6): a sham operation group (Sham group), an operation without fluid therapy group (Shock group), a BRS group, an ARS group, and a normal saline group (Saline group). The New Zealand rabbits experienced rapid bloodletting to shock status and maintained for 20 minutes except Sham group. The status of shock was maintained in the Shock group. The fluid was infused at a rate of 60 mL/kg per hour for 1.5 hours in three fluid therapy group. Measurement of vital signs, arterial blood gas tests, blood biochemistry, hematoxylin and eosin (HE) staining of lung tissue, TUNEL staining of the liver and kidney tissues, and analysis of intestinal flora were performed. Results The reduction in both base excess (BE) and bicarbonate ion (HCO3-) caused by acidosis in rabbits with hemorrhagic shock was significantly improved in the BRS group when compared with the Saline group at infusion for 30 minutes (T3) and 30 minutes after infusion (T5) (BRS group vs. Saline group, BE: at T3, −4.83±3.60 vs. −12.50±3.27 mmol/L, P<0.01; at T5, −3.67±4.37 vs. −11.00±2.76 mmol/L, P<0.01; HCO3-: at T3, 22.15±2.63 vs. 15.42±3.03 mmol/L, P<0.01; at T5, 23.15±2.9 vs. 16.23±3.07 mmol/L, P<0.01). Compared with Shock group, liver cell apoptosis due to hemorrhagic shock was relieved in both the BRS group and ARS group (BRS group vs. Shock group: 19.1±3.3 vs. 28.1±6.1, P<0.05; ARS group vs. Shock group: 19.8±5.4 vs. 28.1±6.1, P<0.05). Conclusions During resuscitation of hemorrhagic shock, BRS, a novel perioperative balanced crystalloid, is more effective than normal saline in maintaining acid-base balance and in protecting tissues and organs.
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Affiliation(s)
- Long Wang
- Department of Anesthesiology, the First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jingsheng Lou
- Department of Anesthesiology, the First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jiangbei Cao
- Department of Anesthesiology, the First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Tao Wang
- New Drug Screening Center/Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, China
| | - Jing Liu
- Department of Anesthesiology, the First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Weidong Mi
- Department of Anesthesiology, the First Medical Center of the Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
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Fort AC, Zack-Guasp RA. Anesthesia for Patients with Extensive Trauma. Anesthesiol Clin 2020; 38:135-148. [PMID: 32008648 DOI: 10.1016/j.anclin.2019.10.012] [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: 11/26/2022]
Abstract
Trauma anesthesiology is a unique and growing subspecialty. With the growing number of adult and pediatric trauma centers in the United States, a thorough understanding of the early management of severely injured patients with trauma is an important aspect of anesthesia. Trauma anesthesiology requires the ability to adapt to different work environments, including the trauma bay, the operating room, and even the intensive care unit, where a patient room may require conversion to an operating suite for emergencies. This article provides a review of the anesthetic management for patients with extensive trauma, focusing on physiology, pharmacology, and bedside management.
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Affiliation(s)
- Alexander C Fort
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, University of Miami, 1611 Northwest 12th Avenue, Suite C300, Miami, FL 33136, USA.
| | - Richard A Zack-Guasp
- Department of Anesthesiology, Bruce W. Carter Medical Center, Department of Veteran's Health Administration, 1201 Northwest 16th Street, Room B333, Miami, FL 33136, USA
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12
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Mould-Millman NK, Dixon J, Lamp A, de Vries S, Beaty B, Finck L, Colborn K, Moodley K, Skenadore A, Glasgow RE, Havranek EP, Bebarta VS, Ginde AA. A single-site pilot implementation of a novel trauma training program for prehospital providers in a resource-limited setting. Pilot Feasibility Stud 2019; 5:143. [PMID: 31844551 PMCID: PMC6896719 DOI: 10.1186/s40814-019-0536-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 11/27/2019] [Indexed: 12/17/2022] Open
Abstract
Background Prehospital (ambulance) care can reduce morbidity and mortality from trauma. Yet, there is a dearth of effective evidence-based interventions and implementation strategies. Emergency Medical Services Traumatic Shock Care (EMS-TruShoC) is a novel bundle of five core evidence-based trauma care interventions. High-Efficiency EMS Training (HEET) is an innovative training and sensitization program conducted during clinical shifts in ambulances. We assess the feasibility of implementing EMS-TruShoC using the HEET strategy, and feasibility of assessing implementation and clinical outcomes. Findings will inform a main trial. Methods We conducted a single-site, prospective cohort, multi-methods pilot implementation study in Western Cape EMS system of South Africa. Of the 120 providers at the study site, 12 were trainers and the remaining were eligible learners. Feasibility of implementation was guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. Feasibility of assessing clinical outcomes was assessed using shock indices and clinical quality of care scores, collected via abstraction of patients' prehospital trauma charts. Thresholds for progression to a main trial were developed a priori. Results The average of all implementation indices was 83% (standard deviation = 10.3). Reach of the HEET program was high, with 84% learners completing at least 75% of training modules. Comparing the proportion of learners attaining perfect scores in post- versus pre-implementation assessments, there was an 8-fold (52% vs. 6%) improvement in knowledge, 3-fold (39% vs. 12%) improvement in skills, and 2-fold (42% vs. 21%) increase in self-efficacy. Clinical outcomes data were successfully calculated-there were clinically significant improvements in shock indices and quality of prehospital trauma care in the post- versus pre-implementation phases. Adoption of HEET was good, evidenced by 83% of facilitator participation in trainings, and 100% of surveyed stakeholders indicating good programmatic fit for their organization. Stakeholders responded that HEET was a sustainable educational solution that aligned well with their organization. Implementation fidelity was very high; 90% of the HEET intervention and 77% of the implementation strategy were delivered as originally planned. Participants provided very positive feedback, and explained that on-the-job timing enhanced their participation. Maintenance was not relevant to assess in this pilot study. Conclusions We successfully implemented the EMS-TruShoC educational intervention using the HEET training strategy in a single-site pilot study conducted in a low-resource international setting. All clinical outcomes were successfully calculated. Overall, this pilot study suggests high feasibility of our future, planned experimental trial.
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Affiliation(s)
- Nee-Kofi Mould-Millman
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA
| | - Julia Dixon
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA
| | - Andrew Lamp
- 1University of Colorado, School of Medicine, Aurora, CO USA
| | - Shaheem de Vries
- Western Cape Government Health, Emergency Medical Services, Bellville, Cape Town, South Africa
| | - Brenda Beaty
- 4Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO USA
| | - Lani Finck
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA
| | - Kathryn Colborn
- 5Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO USA
| | - Kubendhren Moodley
- College of Emergency Care, Western Cape Government, Bellville, Western Cape South Africa
| | - Amanda Skenadore
- 4Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO USA
| | - Russell E Glasgow
- 4Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO USA
| | - Edward P Havranek
- 1University of Colorado, School of Medicine, Aurora, CO USA.,4Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO USA.,7Department of Medicine, Denver Health Medical Center, Denver, CO USA
| | - Vikhyat S Bebarta
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA.,8Office of the Chief Scientist, 59th Medical Wing, Joint Base San Antonio-Lackland, San Antonio, TX USA
| | - Adit A Ginde
- 1University of Colorado, School of Medicine, Aurora, CO USA.,2Department of Emergency Medicine, University of Colorado, School of Medicine, 12401 E. 17th Ave, B215, Aurora, CO 80045 USA
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Mitra B, Bade-Boon J, Fitzgerald MC, Beck B, Cameron PA. Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study. BURNS & TRAUMA 2019; 7:22. [PMID: 31360731 PMCID: PMC6637602 DOI: 10.1186/s41038-019-0160-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/07/2019] [Indexed: 11/10/2022]
Abstract
Background Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients. Methods A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed. Results Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17; 95% confidence interval (CI) 0.03–0.83; p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3; 95% CI 1.4–13.0). Conclusions Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.
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Affiliation(s)
- Biswadev Mitra
- 1National Trauma Research Institute, The Alfred Hospital, 89 Commercial Road, Melbourne, VIC 3004 Australia.,2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.,3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,5Faculty of Medicine, Laval University, Quebec City, Quebec Canada
| | - Jordan Bade-Boon
- 1National Trauma Research Institute, The Alfred Hospital, 89 Commercial Road, Melbourne, VIC 3004 Australia.,2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Mark C Fitzgerald
- 4Trauma Service, The Alfred Hospital, Melbourne, Australia.,5Faculty of Medicine, Laval University, Quebec City, Quebec Canada
| | - Ben Beck
- 3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,5Faculty of Medicine, Laval University, Quebec City, Quebec Canada
| | - Peter A Cameron
- 1National Trauma Research Institute, The Alfred Hospital, 89 Commercial Road, Melbourne, VIC 3004 Australia.,2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.,3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Li Y, Xia X, Li X, Xiao K, Zhuang X. Correlation between the use of antibiotics and development of a resistant bacterial infection in patients in the ICU. Biosci Trends 2019; 12:517-519. [PMID: 30473562 DOI: 10.5582/bst.2018.01130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The current study analyzed the correlation between the use of antibiotics and development of a resistant bacterial infection in 454 patients in intensive care units (ICUs), and this study also examined factors related to development of an infection in order to facilitate more rational use of antibiotics and to reduce the incidence of resistant bacterial infections. Potential subjects were patients who were admitted to the ICU in 2016, and 454 such patients were selected using cluster sampling. Patient information was documented using an original questionnaire, Patients in the ICU with a Resistant Bacterial Infection. The correlation between use of an antibiotic and development of a resistant bacterial infection was examined. The rate of infection significantly increased over time and with receipt of various antibiotics. The development of a resistant bacterial infection was found to correlate with the use of antibiotics. Antibiotics should be used more carefully to reduce the incidence of resistant bacterial infections.
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Affiliation(s)
- Yingxia Li
- General Surgery, Qilu Hospital Affiliated with Shandong University
| | - Xiyan Xia
- Department of Immunology, Jinan Vocational College of Nursing
| | - Xiaohui Li
- Clinical Laboratory, Qilu Hospital Affiliated with Shandong University
| | - Ke Xiao
- Clinical Laboratory, Qilu Hospital Affiliated with Shandong University
| | - Xuewei Zhuang
- Clinical Laboratory, Qilu Hospital Affiliated with Shandong University
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15
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Udyavar NR, Salim A, Havens JM, Cooper Z, Cornwell EE, Lipsitz SR, Scott JW, Haider AH. The impact of individual physicians on outcomes after trauma: is it the system or the surgeon? J Surg Res 2018; 229:51-57. [PMID: 29937016 DOI: 10.1016/j.jss.2018.02.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/29/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Benchmarking of mortality outcomes across the country has revealed major differences in survival based on the trauma center at which a patient receives care. The role of the individual surgeon in determining trauma outcomes is unknown. Most believe that differences in outcomes are primarily driven by system- and process-based variations. Our objective was to determine if variation in individual surgeon outcomes could help explain difference in survival after trauma. METHODS Analysis of trauma patients in the Florida State Inpatient Database from 2010 to 2014. The presence of unique physician identifiers, in addition to hospital identifiers, rendered this data set ideal for performance of multilevel analysis. The amount of the variation attributable to surgeon-level variation was calculated using multilevel random-effects models controlling for patient clinical factors (such as injury severity and comorbidities/age) and hospital-level factors, such as case mix and bed size. RESULTS There were 31 hospitals, 175 surgeons, and 65,706 admissions. The overall mortality rate was 5.6%. The average mortality rate across surgeons ranged from 0% to 17.4% (mean 0.4%, standard deviation 1.85). At the individual surgeon level, when controlling for clinical and hospital-level factors, 9% of this variation was attributable solely to the surgeon. CONCLUSIONS At the state level, we found that differences in outcomes among trauma centers are impacted by individual surgeon-level variation. Implementation of protocolized, system-based trauma care is useful for improving the overall quality of care for injured patients but does not entirely negate surgeon-specific variations in management.
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Affiliation(s)
- N Rhea Udyavar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Ali Salim
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joaquim M Havens
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edward E Cornwell
- Department of Surgery, Howard University Hospital, Washington, District of Columbia
| | - Stuart R Lipsitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - John W Scott
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Affiliation(s)
- Jeremy W Cannon
- From the Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, and the F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD
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Wiles MD. Blood pressure in trauma resuscitation: 'pop the clot' vs. 'drain the brain'? Anaesthesia 2017; 72:1448-1455. [PMID: 28940322 DOI: 10.1111/anae.14042] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M D Wiles
- Department of Anaesthesia, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
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18
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Holcomb JB, Swartz MD, DeSantis SM, Greene TJ, Fox EE, Stein DM, Bulger EM, Kerby JD, Goodman M, Schreiber MA, Zielinski MD, O’Keeffe T, Inaba K, Tomasek JS, Podbielski JM, Appana S, Yi M, Wade CE. Multicenter observational prehospital resuscitation on helicopter study. J Trauma Acute Care Surg 2017; 83:S83-S91. [PMID: 28383476 PMCID: PMC5562146 DOI: 10.1097/ta.0000000000001484] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Earlier use of in-hospital plasma, platelets, and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter. METHODS Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from January to November 2015. Five helicopter systems had plasma and/or RBCs, whereas the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high-risk criteria were analyzed. Patients receiving PHT were compared with patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores. RESULTS Twenty-five thousand one hundred eighteen trauma patients were admitted, 2,341 (9%) were transported by helicopter, of which 1,058 (45%) met the highest-risk criteria. Five hundred eighty-five of 1,058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and Glasgow Coma Scale (7 vs 14) was significantly lower, whereas median Injury Severity Score was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 hours (8.4% vs 3.6%), 24 hours (12.6% vs 8.9%), and 30 days (19.3% vs 13.3%). Twenty-four percent of eligible patients received a PHT. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs, and 69% received both. In the propensity score matching analysis (n = 109), PHT was not significantly associated with mortality at any time point, although only 10% of the high-risk sample were able to be matched. CONCLUSION Because of the unexpected imbalance in systolic blood pressure, Glasgow Coma Scale, and Injury Severity Score between systems with and without blood products on helicopters, matching was limited, and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- John B. Holcomb
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Michael D. Swartz
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Stacia M. DeSantis
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Thomas J. Greene
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Erin E. Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Deborah M. Stein
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M. Bulger
- Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, Seattle, WA
| | - Jeffrey D. Kerby
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Michael Goodman
- Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Martin A. Schreiber
- Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, Portland, OR
| | | | | | | | - Jeffrey S. Tomasek
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Jeanette M. Podbielski
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Savitri Appana
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Misung Yi
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston
| | - Charles E. Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, University of Texas Health Science Center at Houston, Houston, TX
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Oyeniyi BT, Fox EE, Scerbo M, Tomasek JS, Wade CE, Holcomb JB. Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care. Injury 2017; 48:5-12. [PMID: 27847192 PMCID: PMC5193008 DOI: 10.1016/j.injury.2016.10.037] [Citation(s) in RCA: 168] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 10/23/2016] [Accepted: 10/28/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Over the last decade the age of trauma patients and injury mortality has increased. At the same time, many centers have implemented multiple interventions focused on improved hemorrhage control, effectively resulting in a bleeding control bundle of care. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our urban level 1 trauma center. METHODS Records at an urban Level 1 trauma center were reviewed. Two time periods (2005-2006 and 2012-2013) were included in the analysis. Mortality rates were directly adjusted for age, gender and mechanism of injury. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at 0.05. RESULTS 7080 patients (498 deaths) were examined in 2005-2006, while 8767 patients (531 deaths) were reviewed in 2012-2013. The median age increased 6 years, with a similar increase in those who died. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths are now the leading cause of death. Traumatic brain injury (TBI) and hemorrhage accounted for >91% of all deaths. TBI (61%) and multiple organ failure or sepsis (6.2%) deaths were unchanged, while deaths associated with hemorrhage decreased from 36% to 25% (p<0.01). Across time periods, 26% of all deaths occurred within one hour of hospital arrival, while 59% occurred within 24h. Unadjusted mortality dropped from 7.0% to 6.1 (p=0.01) and in-hospital mortality dropped from 6.0% to 5.0% (p<0.01). Adjusted mortality dropped 24% from 7.6% (95% CI: 6.9-8.2) to 5.8% (95% CI: 5.3-6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0-7.2) to 4.7 (95% CI: 4.2-5.1). CONCLUSIONS Over the same time frame of this study, increases in trauma death across the globe have been reported. This single-site study demonstrated a significant reduction in mortality, attributable to decreased hemorrhagic death. It is possible that efforts focused on hemorrhage control interventions (a bleeding control bundle) resulted in this reduction. These changing factors provide guidance on future prevention and intervention efforts.
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Affiliation(s)
- Blessing T. Oyeniyi
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Erin E. Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Michelle Scerbo
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jeffrey S. Tomasek
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Charles E. Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - John B. Holcomb
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Abstract
OPINION STATEMENT Direct oral anticoagulants (DOAC) are an attractive therapeutic option for anticoagulant treatment in the setting of venous thromboembolism or non-valvular atrial fibrillation. These drugs overall appear to have a lower risk of life-threatening hemorrhage than the vitamin K antagonists. In addition, they demonstrate more predictable and stable pharmacokinetics. Measurement of the degree of anticoagulation is desirable in patients with DOAC-associated hemorrhage, but commonly available coagulation assays show poor sensitivity for degree of DOAC effect. DOAC-specific tests are time consuming and not widely available. All coagulation tests should be interpreted considering the timing of last intake and renal function. When life-threatening bleeding occurs, hemostasis should be restored as rapidly as possible. Non-specific prohemostatic drugs may have a role in DOAC reversal, and specific antidotes are at different stages of development. In this review, we provide a summary of DOAC characteristics and an overview of the different therapeutic options available for DOAC reversal.
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