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Rios KE, Alamneh Y, Werner LM, Leung C, Pavlovic R, Abu-Taleb R, Thanapaul RJRS, Lee S, Hull D, Czintos C, Su W, Getnet D, Antonic V, Bobrov AG. Optimization of a Lethal, Combat-Relevant Model of Sterile Inflammation in Mice for Drug Candidate Screening. Mil Med 2024; 189:694-701. [PMID: 39160880 DOI: 10.1093/milmed/usae233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/09/2024] [Accepted: 04/19/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Extensive trauma, commonly seen in wounded military Service Members, often leads to a severe sterile inflammation termed systemic inflammatory response syndrome (SIRS), which can progress to multiple organ dysfunction syndrome (MODS) and death. MODS is a serious threat to wounded Service Members, historically causing 10% of all deaths in trauma admissions at a forward deployed combat hospital. The importance of this problem will be exacerbated in large-scale combat operations, in which evacuation will be delayed and care of complex injuries at lower echelons of care may be prolonged. The main goal of this study was to optimize an existing mouse model of lethal SIRS/MODS as a therapeutic screening platform for the evaluation of immunomodulatory drugs. MATERIALS AND METHODS Male C57BL/6 mice were euthanized, and the bones and muscles were collected and blended into a paste termed tissue-bone matrix (TBX). The TBX at 12.5%-20% relative to body weight of each recipient mouse was implanted into subcutaneous pouches created on the dorsum of anesthetized animals. Mice were observed for clinical scores for up to 48 hours postimplantation and euthanized at the preset point of moribundity. To test effects of anesthetics on TBX-induced mortality, animals received isoflurane or ketamine/xylazine (K/X). In a separate set of studies, mice received TBX followed by intraperitoneal injection with 20 mg/kg or 40 mg/kg Eritoran or a placebo carrier. All Eritoran studies were performed in a blinded fashion. RESULTS We observed that K/X anesthesia significantly increased the lethality of the implanted TBX in comparison to inhaled anesthetics. Although all the mice anesthetized with isoflurane and implanted with 12.5% TBX survived for 24 hours, 60% of mice anesthetized with K/X were moribund by 24 hours postimplantation. To mimic more closely the timing of lethal SIRS/MODS following polytrauma in human patients, we extended observation to 48 hours. We performed TBX dose-response studies and found that as low as 15%, 17.5%, and 20% TBX caused moribundity/mortality in 50%, 80%, and 100% mice, respectively, over a 48-hour time period. With 17.5% TBX, we tested if moribundity/mortality could be rescued by anti-inflammatory drug Eritoran, a toll-like receptor 4 antagonist. Neither 20 mg/kg nor 40 mg/kg doses of Eritoran were found to be effective in this model. CONCLUSIONS We optimized a TBX mouse model of SIRS/MODS for the purpose of evaluating novel therapeutic interventions to prevent trauma-related pathophysiologies in wounded Service Members. Negative effects of K/X on lethality of TBX should be further evaluated, particularly in the light of widespread use of ketamine in treatment of pain. By mimicking muscle crush, bone fracture, and necrosis, the TBX model has pleiotropic effects on physiology and immunology that make it uniquely valuable as a screening tool for the evaluation of novel therapeutics against trauma-induced SIRS/MODS.
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Affiliation(s)
- Kariana E Rios
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830, USA
| | - Yonas Alamneh
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Lacie M Werner
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Clara Leung
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Radmila Pavlovic
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Rania Abu-Taleb
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Rex J R S Thanapaul
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
- NRC Research Associateship Programs, National Academies of Sciences, Engineering, and Medicine, Washington, DC 20001, USA
| | - Sunjoo Lee
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Dawn Hull
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Christine Czintos
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830, USA
| | - Wanwen Su
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Derese Getnet
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Vlado Antonic
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Alexander G Bobrov
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
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Stralec G, Fontaine C, Arras S, Omnes K, Ghomrani H, Lecaros P, Le Conte P, Balen F, Bobbia X. Is a Positive Prehospital FAST Associated with Severe Bleeding? A Multicenter Retrospective Study. PREHOSP EMERG CARE 2023; 28:572-579. [PMID: 37874044 DOI: 10.1080/10903127.2023.2272196] [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: 05/30/2023] [Accepted: 09/23/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Severe hemorrhage is the leading cause of early preventable death in severe trauma patients. Delayed diagnosis is a poor prognostic factor, and severe hemorrhage prediction is essential. The aim of our study was to investigate if there was an association between the detection of peritoneal or pleural fluid on prehospital sonography for trauma and posttraumatic severe hemorrhage. METHODS We retrospectively studied data from records of thoracic or abdominal trauma patients managed in mobile intensive care units from January 2017 to December 2021 in four centers in France. Severe hemorrhage was defined as a condition necessitating transfusion of at least four packed red blood cells or surgical intervention/radioembolization for hemostasis within the first 24 h. Using a multivariate analysis, we investigated the predictive performance of focused assessment with sonography for trauma (FAST) alone or in combination with the five Red Flags criteria validated by Hamada et al. RESULTS Among the 527 patients analyzed, 371 (71%) were men, the mean age was 41 ± 19 years, and the Injury Severity Score was 11 (Interquartile range = [5; 22]). Seventy-three (14%) patients had severe hemorrhage - of whom 28 (38%) had a positive FAST, compared to 61 (13%) without severe hemorrhage (p < 0.01). For severe hemorrhage prediction, FAST had a sensitivity of 38% (95%CI = [27%; 50%]) and a specificity of 87% (95%CI = [83%; 90%]) (AUC = 0.62, 95%CI = [0.57; 0.68]). The comparison of the other outcomes between positive and negative FAST was: hemostatic procedure, 22 (25%) vs 28 (6%), p < 0.01; intensive care unit admission 71 (80%) vs 190 (43%), p < 0.01; mean length of hospital stay 11 [4; 27] vs 4 [0; 14] days, p = 0.02; 30-day mortality 13 (15%) vs 22 (5%), p < 0.01. CONCLUSION A positive FAST performed in the prehospital setting is associated with severe hemorrhage and all prognostic criteria we studied.
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Affiliation(s)
- Grace Stralec
- University of Montpellier, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Camille Fontaine
- Emergency Department, Toulouse University Hospital, Toulouse, France
| | - Sarah Arras
- University of Montpellier, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
| | - Keryann Omnes
- Faculté de médecine, Nantes Université & Service des urgences, CHU de Nantes, France
| | - Hamza Ghomrani
- University of Montpellier, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
| | - Pablo Lecaros
- University of Montpellier, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
| | - Philippe Le Conte
- Faculté de médecine, Nantes Université & Service des urgences, CHU de Nantes, France
| | - Frederic Balen
- Emergency Department, Toulouse University Hospital, Toulouse, France
- Emergency Department, Toulouse University Hospital, CERPOP - EQUITY, INSERM, Toulouse, France
| | - Xavier Bobbia
- University of Montpellier, UR UM 103 (IMAGINE), Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
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Watso JC, Huang M, Hendrix JM, Belval LN, Moralez G, Cramer MN, Foster J, Hinojosa-Laborde C, Crandall CG. Comparing the Effects of Low-Dose Ketamine, Fentanyl, and Morphine on Hemorrhagic Tolerance and Analgesia in Humans. PREHOSP EMERG CARE 2023; 27:600-612. [PMID: 36689353 PMCID: PMC10329983 DOI: 10.1080/10903127.2023.2172493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/09/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023]
Abstract
Hemorrhage is a leading cause of preventable battlefield and civilian trauma deaths. Ketamine, fentanyl, and morphine are recommended analgesics for use in the prehospital (i.e., field) setting to reduce pain. However, it is unknown whether any of these analgesics reduce hemorrhagic tolerance in humans. We tested the hypothesis that fentanyl (75 µg) and morphine (5 mg), but not ketamine (20 mg), would reduce tolerance to simulated hemorrhage in conscious humans. Each of the three analgesics was evaluated independently among different cohorts of healthy adults in a randomized, crossover (within drug/placebo comparison), placebo-controlled fashion using doses derived from the Tactical Combat Casualty Care Guidelines for Medical Personnel. One minute after an intravenous infusion of the analgesic or placebo (saline), we employed a pre-syncopal limited progressive lower-body negative pressure (LBNP) protocol to determine hemorrhagic tolerance. Hemorrhagic tolerance was quantified as a cumulative stress index (CSI), which is the sum of products of the LBNP and the duration (e.g., [40 mmHg x 3 min] + [50 mmHg x 3 min] …). Compared with ketamine (p = 0.002 post hoc result) and fentanyl (p = 0.02 post hoc result), morphine reduced the CSI (ketamine (n = 30): 99 [73-139], fentanyl (n = 28): 95 [68-130], morphine (n = 30): 62 [35-85]; values expressed as a % of the respective placebo trial's CSI; median [IQR]; Kruskal-Wallis test p = 0.002). Morphine-induced reductions in tolerance to central hypovolemia were not well explained by a prediction model including biological sex, body mass, and age (R2=0.05, p = 0.74). These experimental data demonstrate that morphine reduces tolerance to simulated hemorrhage while fentanyl and ketamine do not affect tolerance. Thus, these laboratory-based data, captured via simulated hemorrhage, suggest that morphine should not be used for a hemorrhaging individual in the prehospital setting.
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Affiliation(s)
- Joseph Charles Watso
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, Florida, USA
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mu Huang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Office of Science, Medicine, and Health, American Heart Association, Dallas, Texas, USA
| | - Joseph Maxwell Hendrix
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Luke Norman Belval
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gilbert Moralez
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew Nathaniel Cramer
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josh Foster
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Craig Gerald Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas, USA
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Watso JC, Belval LN, Cimino FA, Orth BD, Hendrix JM, Huang M, Johnson E, Foster J, Hinojosa-Laborde C, Crandall CG. Low-dose morphine reduces tolerance to central hypovolemia in healthy adults without affecting muscle sympathetic outflow. Am J Physiol Heart Circ Physiol 2022; 323:H89-H99. [PMID: 35452317 PMCID: PMC9190738 DOI: 10.1152/ajpheart.00091.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/22/2022]
Abstract
Hemorrhage is a leading cause of preventable battlefield and civilian trauma deaths. Low-dose (i.e., an analgesic dose) morphine is recommended for use in the prehospital (i.e., field) setting. Morphine administration reduces hemorrhagic tolerance in rodents. However, it is unknown whether morphine impairs autonomic cardiovascular regulation and consequently reduces hemorrhagic tolerance in humans. Thus, the purpose of this study was to test the hypothesis that low-dose morphine reduces hemorrhagic tolerance in conscious humans. Thirty adults (15 women/15 men; 29 ± 6 yr; 26 ± 4 kg·m-2, means ± SD) completed this randomized, crossover, double-blinded, placebo-controlled trial. One minute after intravenous administration of morphine (5 mg) or placebo (saline), we used a presyncopal limited progressive lower-body negative pressure (LBNP) protocol to determine hemorrhagic tolerance. Hemorrhagic tolerance was quantified as a cumulative stress index (mmHg·min), which was compared between trials using a Wilcoxon matched-pairs signed-rank test. We also compared muscle sympathetic nerve activity (MSNA; microneurography) and beat-to-beat blood pressure (photoplethysmography) during the LBNP test using mixed-effects analyses [time (LBNP stage) × trial]. Median LBNP tolerance was lower during morphine trials (placebo: 692 [473-997] vs. morphine: 385 [251-728] mmHg·min, P < 0.001, CI: -394 to -128). Systolic blood pressure was 8 mmHg lower during moderate central hypovolemia during morphine trials (post hoc P = 0.02; time: P < 0.001, trial: P = 0.13, interaction: P = 0.006). MSNA burst frequency responses were not different between trials (time: P < 0.001, trial: P = 0.80, interaction: P = 0.51). These data demonstrate that low-dose morphine reduces hemorrhagic tolerance in conscious humans. Thus, morphine is not an ideal analgesic for a hemorrhaging individual in the prehospital setting.NEW & NOTEWORTHY In this randomized, crossover, placebo-controlled trial, we found that tolerance to simulated hemorrhage was lower after low-dose morphine administration. Such reductions in hemorrhagic tolerance were observed without differences in MSNA burst frequency responses between morphine and placebo trials. These data, the first to be obtained in conscious humans, demonstrate that low-dose morphine reduces hemorrhagic tolerance. Thus, morphine is not an ideal analgesic for a hemorrhaging individual in the prehospital setting.
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Affiliation(s)
- Joseph C Watso
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Luke N Belval
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Frank A Cimino
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Bonnie D Orth
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Joseph M Hendrix
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mu Huang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elias Johnson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
| | - Josh Foster
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Carmen Hinojosa-Laborde
- United States Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, Houston, Texas
| | - Craig G Crandall
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, Texas
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas
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Peng HT, Rhind SG, Devine D, Jenkins C, Beckett A. Ex vivo hemostatic and immuno-inflammatory profiles of freeze-dried plasma. Transfusion 2021; 61 Suppl 1:S119-S130. [PMID: 34269465 DOI: 10.1111/trf.16502] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of preventable death in civilian and military trauma. Freeze-dried plasma is promising for hemostatic resuscitation in remote prehospital settings, given its potential benefits in reducing blood loss and mortality, long storage at ambient temperatures, high portability, and rapid reconstitution for transfusion in austere environments. Here we assess the ex vivo characteristics of a novel Terumo's freeze-dried plasma product (TFDP). STUDY DESIGN AND METHODS Rotational thromboelastometry (ROTEM) tests (INTEM, EXTEM, and FIBTEM) were conducted on plasma samples at 37°C with a ROTEM delta-machine using standard reagents and procedures. The following samples were analyzed: pooled plasma to produce TFDP, TFDP reconstituted, and stored immediately at -80°C, reconstituted TFDP stored at 4°C for 24 h and room temperature (RT) for 4 h before freezing at -80°C. Analysis of plasma concentrations of selected cytokines, chemokines, and vascular molecules was performed using a multiplex immunoassay system. One-way ANOVA with post hoc tests assessed differences in hemostatic and inflammatory properties. RESULTS No significant differences in ROTEM variables (coagulation time [CT], clot formation time, α-angle, maximum clot firmness, and lysis index 30) between the TFDP-producing plasma and reconstituted TFDP samples were observed. Compared to control plasma, reconstituted TFDP stored at 4°C for 24 h or RT for 4 h showed a longer INTEM CT. Levels of immuno-inflammatory mediators were similar between frozen plasma and TFDP. CONCLUSIONS TFDP is equivalent to frozen plasma with respect to global hemostatic and immuno-inflammatory mediator profiles. Further investigations of TFDP in trauma-induced coagulopathy models and bleeding patients are warranted.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Shawn G Rhind
- Defence Research and Development Canada, Toronto Research Centre, Toronto, Ontario, Canada
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | | | - Andrew Beckett
- St. Michael's Hospital, Toronto, Ontario, Canada.,Royal Canadian Medical Services, Ottawa, Ontario, Canada
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Cau MF, Strilchuk AW, Kastrup CJ. Nanomedicines for hemorrhage control. J Thromb Haemost 2021; 19:887-891. [PMID: 33694243 DOI: 10.1111/jth.15211] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Massimo F Cau
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada
| | - Amy W Strilchuk
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada
| | - Christian J Kastrup
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada
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Choudhary H, Rudy MB, Dowling MB, Raghavan SR. Foams with Enhanced Rheology for Stopping Bleeding. ACS APPLIED MATERIALS & INTERFACES 2021; 13:13958-13967. [PMID: 33749251 DOI: 10.1021/acsami.0c22818] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Bleeding from injuries to the torso region is a leading cause of fatalities in the military and in young adults. Such bleeding cannot be stopped by applying direct pressure (compression) of a bandage. An alternative is to introduce a foam at the injury site, with the expansion of the foam counteracting the bleeding. Foams with an active hemostatic agent have been tested for this purpose, but the barrier created by these foams is generally not strong enough to resist blood flow. In this paper, we introduce a new class of foams with enhanced rheological properties that enable them to form a more effective barrier to blood loss. These aqueous foams are delivered out of a double-barrelled syringe by combining precursors that produce bubbles of gas (CO2) in situ. In addition, one barrel contains a cationic polymer (hydrophobically modified chitosan, hmC) and the other an anionic polymer (hydrophobically modified alginate, hmA). Both these polymers function as hemostatic agents due to their ability to connect blood cells into networks. The amphiphilic nature of these polymers also enables them to stabilize gas bubbles without the need for additional surfactants. hmC-hmA foams have a mousse-like texture and exhibit a high modulus and yield stress. Their properties are attributed to the binding of hmC and hmA chains (via electrostatic and hydrophobic interactions) to form a coacervate around the gas bubbles. Rheological studies are used to contrast the improved rheology of hmC-hmA foams (where a coacervate arises) with those formed by hmC alone (where there is no such coacervate). Studies with animal wound models also confirm that the hmC-hmA foams are more effective at curtailing bleeding than the hmC foams due to their greater mechanical integrity.
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Affiliation(s)
- Hema Choudhary
- Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, Maryland 20742, United States
| | - Michael B Rudy
- Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, Maryland 20742, United States
| | - Matthew B Dowling
- Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, Maryland 20742, United States
| | - Srinivasa R Raghavan
- Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, Maryland 20742, United States
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Johnson NL, Wade CE, Fox EE, Meyer DE, Fox CJ, Moore EE, Morrison J, Scalea T, Bulger EM, Inaba K, Morse BC, Moore LJ. Determination of optimal deployment strategy for REBOA in patients with non-compressible hemorrhage below the diaphragm. Trauma Surg Acute Care Open 2021; 6:e000660. [PMID: 33693060 PMCID: PMC7907878 DOI: 10.1136/tsaco-2020-000660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 11/29/2022] Open
Abstract
Background Non-compressible truncal hemorrhage (NCTH) is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control, supporting cardiac and cerebral perfusion prior to definitive hemostasis. Aortic zone selection algorithms vary among institutions. We evaluated the efficacy of an algorithm for REBOA use. Methods A multicenter prospective, observational study conducted at six level 1 trauma centers over 12 months. Inclusion criteria were age >15 years with evidence of infradiaphragmatic NCTH needing emergent hemorrhage control within 60 min of ED arrival. An algorithm characterized by the results of focused assessment with sonography in trauma and pelvic X-ray was assessed post hoc for efficacy in a cohort of patients receiving REBOA. Results Of the 8166 patients screened, 78 patients had a REBOA placed. 21 patients were excluded, leaving 57 patients for analysis. The algorithm ensures REBOA deployment proximal to hemorrhage source to control bleeding in 98.2% of cases and accurately predicts the optimal REBOA zone in 78.9% of cases. If the algorithm was violated, bleeding was optimally controlled in only 43.8% (p=0.01). Three (75.0%) of the patients that received an inappropriate zone 1 REBOA died, two from multiple organ failure (MOF). All three patients that died with an inappropriate zone 3 REBOA died from exsanguination. Discussion This algorithm ensures proximal hemorrhage control and accurately predicts the primary source of hemorrhage. We propose a new algorithm that will be more inclusive. A zone 3 REBOA should not be performed when a zone 1 is indicated by the algorithm as 100% of these patients exsanguinated. MOF, perhaps from visceral ischemia in patients with an inappropriate zone 1 REBOA, may have been prevented with zone 3 placement or limited zone 1 occlusion time. Level of evidence Level III.
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Affiliation(s)
- Nicholas L Johnson
- Department of Surgery, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA
| | - Charles E Wade
- Department of Surgery, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA
| | - Erin E Fox
- Department of Surgery, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA
| | - David E Meyer
- Department of Surgery, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA
| | - Charles J Fox
- Department of Surgery, University of Colorado Denver Health Medical Center, Denver, Colorado, USA
| | - Ernest E Moore
- Department of Surgery, University of Colorado Denver Health Medical Center, Denver, Colorado, USA
| | - Jonathan Morrison
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Thomas Scalea
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Kenji Inaba
- Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Bryan C Morse
- Department of Surgery, Emory University School of Medicine Atlanta, Atlanta, Georgia, USA
| | - Laura J Moore
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
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Burn resuscitation strategy influences the gut microbiota-liver axis in swine. Sci Rep 2020; 10:15655. [PMID: 32973266 PMCID: PMC7515893 DOI: 10.1038/s41598-020-72511-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Fluid resuscitation improves clinical outcomes of burn patients; however, its execution in resource-poor environments may have to be amended with limited-volume strategies. Liver dysfunction is common in burn patients and gut dysbiosis is an understudied aspect of burn sequelae. Here, the swine gut microbiota and liver transcripts were investigated to determine the impact of standard-of-care modified Brooke (MB), limited-volume colloid (LV-Co), and limited-volume crystalloid (LV-Cr) resuscitation on the gut microbiota, and to evaluate its' potential relationship with liver dysfunction. Independent of resuscitation strategy, bacterial diversity was reduced 24 h post-injury, and remained perturbed at 48 h. Changes in community structure were most pronounced with LV-Co, and correlated with biomarkers of hepatocellular damage. Hierarchical clustering revealed a group of samples that was suggestive of dysbiosis, and LV-Co increased the risk of association with this group. Compared with MB, LV-Co and LV-Cr significantly altered cellular stress and ATP pathways, and gene expression of these perturbed pathways was correlated with major dysbiosis-associated bacteria. Taken together, LV-Co resuscitation exacerbated the loss of bacterial diversity and increased the risk of dysbiosis. Moreover, we present evidence of a linkage between liver (dys)function and the gut microbiota in the acute setting of burn injury.
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10
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Jung PY, Yu B, Park CY, Chang SW, Kim OH, Kim M, Kwon J, Lee GJ. Clinical Practice Guideline for the Treatment of Traumatic Shock Patients from the Korean Society of Traumatology. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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11
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Abstract
Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma. A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival. A literature search was performed through PubMed, Scopus, and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents, prehospital, battlefield or combat dressings, and prehospital hemostatic resuscitation, followed by cross-reference searching. Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted. Based on these findings, this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings. These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action. Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, 1133 Sheppard Avenue West, Toronto, ON, M3K 2C9, Canada.
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12
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13
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Nessen SC, Le TD, Gurney JM. Combat Casualty Care Statistics as Outcome Measures for Medical Treatment on the Battlefield: A Review and Reconsideration of the Data. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-00177-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Cardi M, Ibrahim K, Alizai SW, Mohammad H, Garatti M, Rainone A, Di Marzo F, La Torre G, Paschetto M, Carbonari L, Mingarelli V, Mingoli A, Sica GS, Sibio S. Injury patterns and causes of death in 953 patients with penetrating abdominal war wounds in a civilian independent non-governmental organization hospital in Lashkargah, Afghanistan. World J Emerg Surg 2019; 14:51. [PMID: 31832085 PMCID: PMC6868865 DOI: 10.1186/s13017-019-0272-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/17/2019] [Indexed: 11/10/2022] Open
Abstract
Background Management of penetrating abdominal war injuries centers upon triage, echeloned care, and damage control. A civilian hospital based in a war zone can rarely rely upon these principles because it normally has limited resources and lacks rapid medical evacuation. We designed this study to describe organ injury patterns and factors related to mortality in patients with penetrating abdominal war injuries in a civilian hospital in an active war zone in Afghanistan, examine how these findings differ from those in a typical military setting, and evaluate how they might improve patients’ care. Methods We reviewed the records of all patients admitted at the Lashkargah “Emergency” hospital with penetrating abdominal injuries treated from January 2006 to December 2016. Demographic and clinical data were recorded; univariate and multivariate analyses were used to identify variables significantly associated with death. Results We treated 953 patients for penetrating abdominal injury. The population was mainly civilian (12.1% women and 21% under 14). Mean age was 23 years, and patients with blast injuries were younger than in the other groups. The mechanism of injury was bullet injury in 589 patients, shell injury in 246, stab wound in 97, and mine injury in 21. The most frequent abdominal lesion was small bowel injury (46.3%). Small and large bowel injuries were the most frequent in the blast groups, stomach injury in stab wounds. Overall mortality was 12.8%. Variables significantly associated with death were age > 34 years, mine and bullet injury, length of stay, time since injury > 5 h, injury severity score > 17, and associated injuries. Conclusions Epidemiology and patterns of injury in a civilian hospital differ from those reported in a typical military setting. Our population is mainly civilian with a significant number of women and patients under 14 years. BI are more frequent than blast injuries, and gastrointestinal injuries are more common than injuries to solid organs. In this austere setting, surgeons need to acquire a wide range of skills from multiple surgical specialties. These findings might guide trauma and general surgeons treating penetrating abdominal war wounds to achieve better care and outcome.
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Affiliation(s)
- Maurizio Cardi
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan.,2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Khushal Ibrahim
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Shah Wali Alizai
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Hamayoun Mohammad
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Marco Garatti
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan.,Chirurgia Generale, Fondazione Poliambulanza, Istituto Ospedaliero, Via Bissolati 57, Brescia, Italy
| | - Antonio Rainone
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Francesco Di Marzo
- 4Chirurgia Generale, Ospedale Versilia, Via Aurelia 335, 55041 Lido di Camaiore, LU Italy
| | - Giuseppe La Torre
- 5Dipartimento di Sanità Pubblica e Malattie Infettive, Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Michela Paschetto
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
| | - Ludovica Carbonari
- 2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Valentina Mingarelli
- 2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Andrea Mingoli
- 2Dipartimento di Chirurgia "P. Valdoni", Sapienza Università di Roma, Viale del Policlinico155, 00161 Rome, Italy
| | - Giuseppe S Sica
- 6Dipartimento di Chirurgia, Università Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Simone Sibio
- Emergency NGO Medical Division, Lashkargah Hospital, Lashkargah, Afghanistan
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15
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Adams L, Tucker A, Dennis JA, Dissanaike S. Impact of time spent in the trauma bay on mortality outcomes among level 1 trauma patients. TRAUMA-ENGLAND 2019. [DOI: 10.1177/1460408618789964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction The majority of trauma-related deaths occur within the first 24 h of injury, and time elapsed until intervention for an injury is one of the greatest causes of preventable death in mature trauma centers. This study seeks to determine if there is a correlation between time spent in the trauma bay and mortality outcomes. Methods A retrospective analysis of Level 1 trauma patients from 1 January 2010 to 1 January 2016 in a single center. Results Charts from 1678 Level 1 trauma patients with 1290 (76.9%) blunt and 388 (23.1%) penetrating injuries were analyzed. Of these, 345 patients died and 237 (68.7%) died within the first 24 h. Multivariate analysis yields an inverse correlation between increased times spent in the trauma bay and mortality, with controls for injury severity, age, and race/ethnicity and with deaths in the trauma bay excluded ( p < 0.001). Each additional minute spent in the trauma bay increases odds of surviving by 1%. However, increase in ISS and decrease in TRISS were directly correlated with reduced time in the trauma bay for both blunt and penetrating traumas. Results did not differ based on mechanism of injury or destination after the trauma bay. Conclusion Reduced time spent in trauma bay was not correlated with improved mortality outcomes in Level 1 trauma patients. Findings do not necessarily suggest that increased trauma bay time would reduce mortality, but rather current evaluation procedures may prioritize trauma patients appropriately. Instinctive adjustment by emergency care providers to move more severely injured patients out of the trauma bay quicker and other additional variables could account for the measured phenomena. This is the first study to examine trauma bay times and mortality outcomes.
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Affiliation(s)
- Logan Adams
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Amber Tucker
- Trauma and Burn Service Department, University Medical Center, Lubbock, TX, USA
| | - Jeff A. Dennis
- Department of Public Health, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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16
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Janak J, Stockinger Z, Mazuchowski E, Kotwal R, Sosnov J, Montgomery H, Butler F, Shackelford S, Gurney J, Spott M, Finelli L, Smith DJ. Military Preventable Death Conceptual Framework: A Systematic Approach for Reducing Battlefield Mortality. Mil Med 2019; 183:15-23. [PMID: 30189080 DOI: 10.1093/milmed/usy149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Indexed: 11/13/2022] Open
Abstract
The National Academies of Sciences, Engineering, and Medicine Report on Zero Preventable Deaths highlighted the need for a military and civilian partnership to take lessons learned from the wars in Iraq and Afghanistan and incorporate them into a national learning trauma care system. One of the specific objectives in the report was to establish military preventable death metrics. Upon further inspection, it became apparent that the Department of Defense did not have an established methodology to reliably estimate and report preventable death metrics and opportunities to improve the military trauma care system. Over the last year, clinical and non-clinical subject matter experts from the Joint Trauma System and Armed Forces Medical Examiners System began the process of establishing a standard military preventable death review process to meet the objective outlined in the report. Based on an assessment to understand methodological best practices for preventable death reviews, this manuscript presents the conceptual framework that is guiding our effort to establish the first ever battle-related mortality surveillance system with preventable death metrics and opportunities to improve the trauma care system.
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Affiliation(s)
- Jud Janak
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Zsolt Stockinger
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Edward Mazuchowski
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Russ Kotwal
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jonathan Sosnov
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Harold Montgomery
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Frank Butler
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Stacy Shackelford
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Jennifer Gurney
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Mary Spott
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Louis Finelli
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - David J Smith
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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17
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Thompson KB, Krispinsky LT, Stark RJ. Late immune consequences of combat trauma: a review of trauma-related immune dysfunction and potential therapies. Mil Med Res 2019; 6:11. [PMID: 31014397 PMCID: PMC6480837 DOI: 10.1186/s40779-019-0202-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/07/2019] [Indexed: 12/29/2022] Open
Abstract
With improvements in personnel and vehicular body armor, robust casualty evacuation capabilities, and damage control resuscitation strategies, more combat casualties are surviving to reach higher levels of care throughout the casualty evacuation system. As such, medical centers are becoming more accustomed to managing the deleterious late consequences of combat trauma related to the dysregulation of the immune system. In this review, we aim to highlight these late consequences and identify areas for future research and therapeutic strategies. Trauma leads to the dysregulation of both the innate and adaptive immune responses, which places the injured at risk for several late consequences, including delayed wound healing, late onset sepsis and infection, multi-organ dysfunction syndrome, and acute respiratory distress syndrome, which are significant for their association with the increased morbidity and mortality of wounded personnel. The mechanisms by which these consequences develop are complex but include an imbalance of the immune system leading to robust inflammatory responses, triggered by the presence of damage-associated molecules and other immune-modifying agents following trauma. Treatment strategies to improve outcomes have been difficult to develop as the immunophenotype of injured personnel following trauma is variable, fluid and difficult to determine. As more information regarding the triggers that lead to immune dysfunction following trauma is elucidated, it may be possible to identify the immunophenotype of injured personnel and provide targeted treatments to reduce the late consequences of trauma, which are known to lead to significant morbidity and mortality.
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Affiliation(s)
- Kelly B Thompson
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, 2200 Children's Way, Nashville, TN, 37232, USA.
| | - Luke T Krispinsky
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Uniformed Services University, Naval Medical Center Portsmouth, Portsmouth, VA, 23708, USA
| | - Ryan J Stark
- Division of Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, 2200 Children's Way, Nashville, TN, 37232, USA
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18
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 695] [Impact Index Per Article: 139.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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19
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Williams AM, Bhatti UF, Dennahy IS, Graham NJ, Nikolian VC, Chtraklin K, Chang P, Zhou J, Biesterveld BE, Eliason J, Alam HB. Traumatic brain injury may worsen clinical outcomes after prolonged partial resuscitative endovascular balloon occlusion of the aorta in severe hemorrhagic shock model. J Trauma Acute Care Surg 2019; 86:415-423. [PMID: 30605139 PMCID: PMC6715315 DOI: 10.1097/ta.0000000000002149] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The use of partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) in combined hemorrhagic shock (HS) and traumatic brain injury (TBI) has not been well studied. We hypothesized that the use of pREBOA in the setting of TBI would be associated with worse clinical outcomes. METHODS Female Yorkshire swine were randomized to the following groups: HS-TBI, HS-TBI-pREBOA, and HS-pREBOA (n = 5/cohort). Animals in the HS-TBI group were left in shock for a total of 2 hours, whereas animals assigned to pREBOA groups were treated with supraceliac pREBOA deployment (60 minutes) 1 hour into the shock period. All animals were then resuscitated, and physiologic parameters were monitored for 6 hours. Further fluid resuscitation and vasopressors were administered as needed. At the end of the observation period, brain hemispheric swelling (%) and lesion size (mm) were assessed. RESULTS Mortality was highest in the HS-TBI-pREBOA group (40% [2/5] vs. 0% [0/5] in the other groups, p = 0.1). Severity of shock was greatest in the HS-TBI-pREBOA group, as defined by peak lactate levels and pH nadir (p < 0.05). Fluid resuscitation and norepinephrine requirements were significantly higher in the HS-TBI-pREBOA group (p < 0.05). No significant differences were noted in brain hemispheric swelling and lesion size between the groups. CONCLUSION Prolonged application of pREBOA in the setting of TBI does not contribute to early worsening of brain lesion size and edema. However, the addition of TBI to HS-pREBOA may worsen the severity of shock. Providers should be aware of the potential physiologic sequelae induced by TBI.
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Affiliation(s)
| | - Umar F. Bhatti
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Nathan J. Graham
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Kiril Chtraklin
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Panpan Chang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jing Zhou
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Jonathan Eliason
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Hasan B. Alam
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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20
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Barroso J, Osborne B, Teramura G, Pellham E, Fitzpatrick M, Biehl R, Yu A, Pehta J, Slichter SJ. Safety evaluation of a lyophilized platelet-derived hemostatic product. Transfusion 2018; 58:2969-2977. [PMID: 30450601 DOI: 10.1111/trf.14972] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemorrhage causes significant morbidity and mortality in people aged <65 years. A lyophilized platelet-derived hemostatic agent (Thrombosomes) demonstrated hemostatic efficacy in animal models. We report the results of the first safety trial of autologous Thrombosomes given to normal subjects. STUDY DESIGN AND METHODS Ten subjects received autologous Thrombosomes prepared from their apheresis platelets, and five control subjects received a buffer solution. There were five cohorts, with three subjects per cohort (two in the Thrombosomes group and one in the control group). Doses escalated from 1/1,000 to 1/10 of a proposed efficacious dose. Cohorts 4 and 5 received the highest dose, but in Cohort 5, one-half the dose was infused 2 hours apart. Cohorts 1 through 3 were monitored for 42 days, Cohorts 4 and 5 were monitored for 60 days using hematology, coagulation, and chemistry assays and antibody testing. RESULTS There were no serious adverse events (AEs) and no subject withdrawals. There were eight treatment-related AEs (TRAEs) in 5 of 15 subjects (33%) (four in the Thrombosomes group and one in the control group). Of four subjects receiving the highest doses, three had TRAEs. One had elevated D-dimer, prothrombin fragment 1 + 2, and white blood cell count (subject had concurrent upper respiratory tract infection); one had T-wave inversions in precordial leads V2 and V3 without elevated troponin or symptoms; and one had a platelet autoantibody without change in platelet count. All subjects' TRAEs resolved by Day 21. CONCLUSION There were no serious AEs in this small study. Thrombosomes were considered safe at the doses assessed. Future, larger trials will be needed to further assess safety and efficacy.
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Affiliation(s)
- Jeffrey Barroso
- Research Institute, Bloodworks Northwest, Seattle, Washington
| | - Barbara Osborne
- Research Institute, Bloodworks Northwest, Seattle, Washington
| | - Gayle Teramura
- Research Institute, Bloodworks Northwest, Seattle, Washington
| | - Esther Pellham
- Research Institute, Bloodworks Northwest, Seattle, Washington
| | | | | | - Anna Yu
- Cellphire, Inc., Rockville, Maryland
| | | | - Sherrill J Slichter
- Research Institute, Bloodworks Northwest, Seattle, Washington.,University of Washington School of Medicine, Seattle, Washington
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21
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Douma MJ, Picard C, O'Dochartaigh D, Brindley PG. Proximal External Aortic Compression for Life-Threatening Abdominal-Pelvic and Junctional Hemorrhage: An Ultrasonographic Study in Adult Volunteers. PREHOSP EMERG CARE 2018; 23:538-542. [PMID: 30285523 DOI: 10.1080/10903127.2018.1532477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Introduction: Following life-threatening junctional trauma, the goal is to limit blood loss while expediting transfer to operative rescue. Unfortunately, life-threatening abdominal-pelvic or junctional hemorrhage is often not amenable to direct compression and few temporizing strategies are available beyond hemostatic dressings, hypotensive resuscitation, and balanced transfusion. Objectives: In this study, we evaluated proximal external aortic compression to arrest blood flow in healthy adult men. Methods: This was a simulation trial of proximal external aortic compression, for life-threatening abdominal-pelvic and junctional hemorrhage, in a convenience sample of healthy adult male volunteers. The primary end points were cessation of femoral blood flow as assessed by pulse wave Doppler ultrasound at the right femoral artery, caudal to the inguinal ligament. Secondary end points were discomfort and negative sequelae. Results: Aortic blood flow was arrested in 12 volunteers. Median time to blood flow cessation was 12.5 seconds. Median reported discomfort was 5 out of 10. No complications or negative sequelae were reported. Conclusion: This trial suggests that it may be reasonable to attempt temporization of major abdominal-pelvic and junctional hemorrhage using bimanual proximal external aortic compression. In the absence of immediate alternatives for this dangerous and vexing injury pattern, there appear to be few downsides to prehospital proximal external aortic compression while concomitantly expediting definite care.
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22
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Jung A, Johnson M, Veile R, Friend LA, Stevens-Topie S, Elterman J, Pritts T, Makley A, Goodman M. Variable saline resuscitation in a murine model of combined traumatic brain injury and haemorrhage. Brain Inj 2018; 32:1834-1842. [PMID: 30136863 DOI: 10.1080/02699052.2018.1510542] [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: 10/28/2022]
Abstract
BACKGROUND Resuscitation strategies for combined traumatic brain injury (TBI) with haemorrhage in austere environments are not fully established. Our aim was to establish the effects of various saline concentrations in a murine model of combined TBI and haemorrhage, and identify an effective resuscitative strategy for the far-forward environment. METHODS Male C57BL/6 mice underwent closed head injury and subjected to controlled haemorrhage to a systolic blood pressure of 25 mmHg via femoral artery cannulation for 60 min. Mice were resuscitated with a fixed volume bolus or variable volumes of fluid to achieve a systolic blood pressure goal of 80 mmHg with 0.9% saline, 3% saline, 0.1-mL bolus of 23.4% saline, or a 0.1-mL bolus of 23.4% saline followed by 0.9% saline (23.4+). RESULTS 23.4% saline and 23.4+ resulted in higher mortality at 6 h compared to 0.9% saline. Use of 3% saline required less volume to achieve targeted resuscitation, did not affect survival, and did not exacerbate post-traumatic inflammation. While 23.4+ resuscitation utilized lower volume, it resulted in hypernatremia, azotemia, and elevated systemic pro-inflammatory cytokines. All groups except 3% saline demonstrated progression of neuron damage, with cerebral oedema highest with 0.9% saline. CONCLUSIONS 3% saline demonstrated favourable balance of survival, blood pressure restoration, minimization of inflammation, and prevention of ongoing neurologic injury without contributing to significant physiologic derangements. 23.4% saline administration may not be appropriate in the setting of concomitant hypotension.
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Affiliation(s)
- Andrew Jung
- a Division of Research, Institute for Military Medicine, Department of Surgery , University of Cincinnati , Cincinnati , OH , USA
| | - Mark Johnson
- a Division of Research, Institute for Military Medicine, Department of Surgery , University of Cincinnati , Cincinnati , OH , USA
| | - Rosalie Veile
- a Division of Research, Institute for Military Medicine, Department of Surgery , University of Cincinnati , Cincinnati , OH , USA
| | - Lou Ann Friend
- a Division of Research, Institute for Military Medicine, Department of Surgery , University of Cincinnati , Cincinnati , OH , USA
| | - Sabre Stevens-Topie
- a Division of Research, Institute for Military Medicine, Department of Surgery , University of Cincinnati , Cincinnati , OH , USA
| | - Joel Elterman
- a Division of Research, Institute for Military Medicine, Department of Surgery , University of Cincinnati , Cincinnati , OH , USA
| | - Timothy Pritts
- a Division of Research, Institute for Military Medicine, Department of Surgery , University of Cincinnati , Cincinnati , OH , USA
| | - Amy Makley
- a Division of Research, Institute for Military Medicine, Department of Surgery , University of Cincinnati , Cincinnati , OH , USA
| | - Michael Goodman
- a Division of Research, Institute for Military Medicine, Department of Surgery , University of Cincinnati , Cincinnati , OH , USA
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Kemp Bohan P, Schreiber MA. Resuscitation. MANAGING DISMOUNTED COMPLEX BLAST INJURIES IN MILITARY & CIVILIAN SETTINGS 2018. [PMCID: PMC7122077 DOI: 10.1007/978-3-319-74672-2_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Blast injuries can produce complex patterns of injury and can easily result in hemorrhagic shock. Adequate resuscitation of blast-injured patients is critical, as both under- and over-resuscitation can result in a number of fatal complications. Consideration must be given to the choice of resuscitative fluid, the volume of resuscitation, the timing of resuscitation relative to definitive surgical management, and the determination of endpoints at which resuscitation can be stopped. This chapter explores resuscitation of blast-injured patients, beginning in the prehospital phase with initial choice of fluid and continuing through definitive resuscitation at a higher echelon of care. Particular consideration is given to the effect of resuscitation on the unique physiologic derangements seen following blast injury. Drawing upon the enormous amount of literature on resuscitation from the recent coalition experiences in Iraq and Afghanistan, we advocate for the use of early hemostatic resuscitation with a high ratio of plasma, platelets, and packed red blood cells, with a transition to resuscitation guided by viscoelastic testing or coagulation status immediately following definitive control of hemorrhage.
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Black GE, Sokol KK, Moe DM, Simmons JD, Muscat D, Pastukh V, Capley G, Gorodnya O, Ruchko M, Roth MB, Gillespie M, Martin MJ. Impact of a novel phosphoinositol-3 kinase inhibitor in preventing mitochondrial DNA damage and damage-associated molecular pattern accumulation: Results from the Biochronicity Project. J Trauma Acute Care Surg 2017; 83:683-689. [PMID: 28930961 PMCID: PMC5938741 DOI: 10.1097/ta.0000000000001593] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite improvements in the management of severely injured patients, development of multiple organ dysfunction syndrome (MODS) remains a morbid complication of traumatic shock. One of the key attributes of MODS is a profound bioenergetics crisis, for which the mediators and mechanisms are poorly understood. We hypothesized that metabolic uncoupling using an experimental phosphoinositol-3 kinase (PI3-K) inhibitor, LY294002 (LY), may prevent mitochondrial abnormalities that lead to the generation of mitochondrial DNA (mtDNA) damage and the release of mtDNA damage-associated molecular patterns (DAMPs). METHODS Sixteen swine were studied using LY, a nonselective PI3-K inhibitor. Animals were assigned to trauma only (TO, n = 3), LY drug only (LYO, n = 3), and experimental (n = 10), trauma + drug (LY + T) groups. Both trauma groups underwent laparotomy, 35% hemorrhage, severe ischemia-reperfusion injury, and protocolized resuscitation. A battery of hemodynamic, laboratory, histological, and bioenergetics parameters were monitored. Mitochondrial DNA damage was determined in lung, liver, and kidney using Southern blot analyses, whereas plasma mtDNA DAMP analysis used polymerase chain reaction amplification of a 200-bp sequence of the mtDNA D-loop region. RESULTS Relative to control animals, H + I/R (hemorrhage and ischemia/reperfusion) produced severe, time-dependent decrements in hepatic, renal, cardiovascular, and pulmonary function accompanied by severe acidosis and lactate accumulation indicative of bioenergetics insufficiency. The H-I/R animals displayed prominent oxidative mtDNA damage in all organs studied, with the most prominent damage in the liver. Mitochondrial DNA damage was accompanied by accumulation of mtDNA DAMPs in plasma. Pretreatment of H + I/R animals with LY resulted in profound metabolic suppression, with approximately 50% decreases in O2 consumption and CO2 production. In addition, it prevented organ and bioenergetics dysfunction and was associated with a significant decrease in plasma mtDNA DAMPs to the levels of control animals. CONCLUSIONS These findings show that H + I/R injury in anesthetized swine is accompanied by MODS and by significant mitochondrial bioenergetics dysfunction, including oxidative mtDNA damage and accumulation in plasma of mtDNA DAMPs. Suppression of these changes with the PI3-K inhibitor LY indicates that pharmacologically induced metabolic uncoupling may comprise a new pharmacologic strategy to prevent mtDNA damage and DAMP release and prevent or treat trauma-related MODS. LEVEL OF EVIDENCE Therapeutic study, level III.
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Affiliation(s)
- George Edward Black
- From the Department of Surgery (G.E.B., K.K.S., D.M.M., M.J.M.), Madigan Army Medical Center, Joint Base Lewis-McChord, Washington; Department of Surgery (J.S.), University of South Alabama, Mobile, Alabama; Department of Pharmacology (D.M., V.P., G.C., O.G., M.R., M.G.), University of South Alabama, Mobile, Alabama; Basic Sciences Division (M.B.R.), Fred Hutchinson Cancer Research Center, Seattle, Washington; and Trauma and Acute Care Surgery Service (M.J.M.), Legacy Emanuel Medical Center, Portland, Oregon
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Blackman VS, Cooper BA, Puntillo K, Franck LS. Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010-2013. J Trauma Nurs 2017; 23:257-74. [PMID: 27618374 DOI: 10.1097/jtn.0000000000000231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.Pain scores were documented in 60.5% (n = 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60-100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).Pain severity scores ranged from 0 to 10; mean = 5.5 (SD = 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.
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Affiliation(s)
- Virginia Schmied Blackman
- Nurse Corps, U.S. Navy, Walter Reed National Military Medical Center, Department of Research Programs, Center for Nursing Science and Clinical Inquiry, Bethesda, Maryland (Dr Blackman); and School of Nursing, University of California, San Francisco (Drs Blackman, Cooper, Puntillo, and Franck)
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Giannakopoulos TG, Avgerinos ED. Management of Peripheral and Truncal Venous Injuries. Front Surg 2017; 4:46. [PMID: 28884115 PMCID: PMC5573711 DOI: 10.3389/fsurg.2017.00046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/08/2017] [Indexed: 12/19/2022] Open
Abstract
Civilian injuries are increasing according to the World Health Organization, and this is attributed mainly to road traffic accidents and urban interpersonal violence. Vascular injuries are common in these scenarios and are associated with high morbidity and mortality rates. Associated peripheral venous trauma is less likely to lead to death and controversy remains whether ligation or repair should be the primary approach. Conversely, non-compressible truncal venous insult can be lethal due to exsanguination, thus a high index of suspicion is crucial. Operative management is demanding with fair results but recent endovascular adjuncts demonstrate promising results and seem to be the way forward for these serious conditions.
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Affiliation(s)
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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There's an app for that: A handheld smartphone-based infrared imaging device to assess adequacy and level of aortic occlusion during REBOA. J Trauma Acute Care Surg 2017; 82:102-108. [PMID: 27805993 DOI: 10.1097/ta.0000000000001264] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Advances in thermal imaging devices have made them an appealing noninvasive point-of-care imaging adjunct in the trauma setting. We sought to assess whether a smartphone-based infrared imaging device (SBIR) could determine presence and location of aortic occlusion in a swine model. We hypothesized that various levels of aortic occlusion would transmit significantly different heat signatures at various anatomical points. METHODS Six swine (35-50 kg) underwent sequential zone 1 (Z1) aortic cross clamping as well as zone 3 (Z3) aortic balloon occlusion (resuscitative endovascular balloon occlusion of the aorta [REBOA]). SBIR images and readings (FLIR One) were taken at five anatomic points (axilla [A], subcostal [S], umbilical [U], inguinal [I], medial malleolar [M]) and were used to determine significant thermal trends 5 minutes to 10 minutes after Z1 and Z3 occlusion. Significant (p ≤ 0.05) thermal ratio patterns were identified and compared among groups, and images were reviewed for obvious qualitative differences at the various levels of occlusion. RESULTS Body temperatures were similar during control (CON), Z1 occlusion, and Z3 occlusion, ranging from 94.0 °F to 100.9 °F (p = 0.126). No significant temperature differences were found among A, S, U, I, M points prior to and after aortic occlusions. Among the anatomical 2-point ratios evaluated, A/M and S/M ratios were the best predictors of aortic occlusion, whether at Z1 (8.2 °F, p < 0.01; 10.9 °F, p < 0.01) or Z3 (7.3 °F, p < 0.01; 8.4 °F, p < 0.01), respectively. The best predictor of Z1 versus Z3 level of occlusion was the S/I ratio (5.2 °F, p < 0.05 vs. 3.4 °F, p = 0.27). SBIR generated qualitatively different thermal signatures among groups. CONCLUSION SBIR was capable of detecting thermal trends during Z1 and Z3 aortic occlusion by using an anatomical 2-point thermal ratio. There were also easily recognized qualitative differences between control and occlusion images that would allow immediate determination of adequate occlusion of the aorta. SBIR represents a potential inexpensive and accurate tool for assessing perfusion, adequate REBOA placement, and even the aortic level of occlusion.
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Eastridge BJ. Injuries to the Abdomen from Explosion. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0079-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Douma MJ, O'Dochartaigh D, Brindley PG. Optimization of indirect pressure in order to temporize life-threatening haemorrhage: A simulation study. Injury 2016; 47:1903-7. [PMID: 27354300 DOI: 10.1016/j.injury.2016.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 05/15/2016] [Accepted: 06/03/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Minimizing haemorrhage using direct pressure is intuitive and widely taught. In contrast, this study examines the use of indirect-pressure, specifically external aortic compression (EAC). Indirect pressure has great potential for temporizing bleeds not amenable to direct tamponade i.e. abdominal-pelvic, junctional, and multi-site trauma. However, it is currently unclear how to optimize this technique. METHODS We designed a model of central vessel compression using the Malbrain intra-abdominal pressure monitor and digital weigh scale. Forty participants performed simulated external aortic compression on the ground, on a stretcher mattress, and with and without a backboard. RESULTS The greater the rescuer's bodyweight the greater was their mean compression (Pearson's correlation 0.93). Using one-hand, a mean of 28% participant bodyweight (95% CI, 26-30%) could be transmitted at sustainable effort, waist-height, and on a stretcher. A second compressing hand increased the percentage of rescuer bodyweight transmission 10-22% regardless of other factors (i.e. presence/absence or a backboard; rescuer position) (p<0.001). Adding a backboard increased transmission of rescuer bodyweight 7-15% (p<0.001). Lowering the patient from waist-height backboard to the floor increased transmission of rescuer bodyweight 4-9% (p<0.001). Kneeling on the model was the most efficient method and transmitted 11% more weight compared to two-handed maximal compression (p<0.001). CONCLUSIONS Efficacy is maximized with larger-weight rescuers who use both hands, position themselves atop victims, and compress on hard surfaces/backboards. Knee compression is most effective and least fatiguing, thus assisting rescuers of lower weight and lesser strength, where no hard surfaces exist (i.e. no available backboard or trauma on soft ground), or when lengthy compression is required (i.e. remote locations). Our work quantifies methods to optimize indirect pressure as a temporizing measure following life-threatening haemorrhage not amenable to direct compression, and while expediting compression devices or definitive treatment.
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Affiliation(s)
- Matthew J Douma
- Trauma and Emergency Services, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, Alberta, T5H3V9, Canada.
| | - Domhnall O'Dochartaigh
- Shock Trauma Air Rescue Society, Canada; Emergency Services, Edmonton, Alberta Health Services, Canada.
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Jiang L, Zhang M. Who will benefit from whole-body computed tomography? Am J Emerg Med 2016; 34:1907-8. [DOI: 10.1016/j.ajem.2016.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 07/06/2016] [Indexed: 10/21/2022] Open
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The impact of short prehospital times on trauma center performance benchmarking: An ecologic study. J Trauma Acute Care Surg 2016; 80:586-94; discussion 594-6. [PMID: 26808027 DOI: 10.1097/ta.0000000000000974] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency medical service (EMS) prehospital times vary between regions, yet the impact of local prehospital times on trauma center (TC) performance is unknown. To inform external benchmarking efforts, we explored the impact of EMS prehospital times on the risk-adjusted rate of emergency department (ED) death and overall hospital mortality at urban TCs across the United States. METHODS We used a novel ecologic study design, linking EMS data from the National EMS Information System to TCs participating in the American College of Surgeons' Trauma Quality Improvement Program (TQIP) by destination zip code. This approach provided EMS times for populations of injured patients transported to TQIP centers. We defined the exposure of interest as the 90th percentile total prehospital time (PHT) for each TC. TCs were then stratified by PHT quartile. Analyses were limited to adult patients with severe blunt or penetrating trauma, transported directly by land to urban TQIP centers. Random-intercept multilevel modeling was used to evaluate the risk-adjusted relationship between PHT quartile and the outcomes of ED death and overall hospital mortality. RESULTS During the study period, 119,740 patients met inclusion criteria at 113 TCs. ED death occurred in 1% of patients, and overall mortality was 7.2%. Across all centers, the median PHT was 61 minutes (interquartile range, 53-71 minutes). After risk adjustment, TCs in regions with the shortest quartile of PHTs (<53 minutes) had significantly greater odds of ED death compared with those with the longest PHTs (odds ratio, 2.00; 95% confidence interval, 1.43-2.78). However, there was no association between PHT and overall TC mortality. CONCLUSION At urban TCs, local EMS prehospital times are a significant predictor of ED death. However, no relationship exists between prehospital time and overall TC risk-adjusted mortality. Therefore, there is no evidence for the inclusion of EMS prehospital time in external benchmarking analyses.
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Chaturvedi A, Dowling MB, Gustin JP, Scalea TM, Raghavan SR, Pasley JD, Narayan M. Hydrophobically modified chitosan gauze: a novel topical hemostat. J Surg Res 2016; 207:45-52. [PMID: 27979487 DOI: 10.1016/j.jss.2016.04.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 02/11/2016] [Accepted: 04/20/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Currently, the standard of care for treating severe hemorrhage in a military setting is Combat Gauze (CG). Previous work has shown that hydrophobically modified chitosan (hm-C) has significant hemostatic capability relative to its native chitosan counterpart. This work aims to evaluate gauze coated in hm-C relative to CG as well as ChitoGauze (ChG) in a lethal in vivo hemorrhage model. METHODS Twelve Yorkshire swine were randomized to receive either hm-C gauze (n = 4), ChG (n = 4), or CG (n = 4). A standard hemorrhage model was used in which animals underwent a splenectomy before a 6-mm punch arterial puncture of the femoral artery. Thirty seconds of free bleeding was allowed before dressings were applied and compressed for 3 min. Baseline mean arterial pressure was preserved via fluid resuscitation. Experiments were conducted for 3 h after which any surviving animal was euthanized. RESULTS hm-C gauze was found to be at least equivalent to both CG and ChG in terms of overall survival (100% versus 75%), number of dressing used (6 versus 7), and duration of hemostasis (3 h versus 2.25 h). Total post-treatment blood loss was lower in the hm-C gauze treatment group (4.7 mL/kg) when compared to CG (13.4 mL/kg) and ChG (12.1 mL/kg) groups. CONCLUSIONS hm-C gauze outperformed both CG and ChG in a lethal hemorrhage model but without statistical significance for key endpoints. Future comparison of hm-C gauze to CG and ChG will be performed on a hypothermic, coagulopathic model that should allow for outcome significance to be differentiated under small treatment groups.
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Affiliation(s)
- Apurva Chaturvedi
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, Baltimore, Maryland
| | - Matthew B Dowling
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland
| | - John P Gustin
- Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, Maryland
| | - Thomas M Scalea
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland
| | - Srinivasa R Raghavan
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland; Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, Maryland
| | - Jason D Pasley
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, Baltimore, Maryland
| | - Mayur Narayan
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, School of Medicine, Baltimore, Maryland.
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Blackman VS, Cooper BA, Puntillo K, Franck LS. Prevalence and Predictors of Prehospital Pain Assessment and Analgesic Use in Military Trauma Patients, 2010–2013. PREHOSP EMERG CARE 2016; 20:737-751. [DOI: 10.1080/10903127.2016.1182601] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Rasmussen TE, Baer DG, Cap AP, Lein BC. Ahead of the curve: Sustained innovation for future combat casualty care. J Trauma Acute Care Surg 2016; 79:S61-4. [PMID: 26406437 DOI: 10.1097/ta.0000000000000795] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Todd E Rasmussen
- From the US Combat Casualty Care Research Program (T.E.R., D.G.B., B.C.L.), US Army Medical Research and Materiel Command, Fort Detrick, Frederick; and Norman M. Rich Department of Surgery (T.E.R.), The Uniformed Services University of the Health Sciences, Bethesda, Maryland; and US Army Institute of Surgical Research (A.P.C.), Joint Base Fort Sam Houston, San Antonio, Texas
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Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg 2015; 79:523-30; discussion 530-2. [PMID: 26402524 DOI: 10.1097/ta.0000000000000809] [Citation(s) in RCA: 228] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemorrhage remains the leading cause of death in trauma patients. Proximal aortic occlusion, usually performed by direct aortic cross-clamping via thoracotomy, can provide temporary hemodynamic stability, permitting definitive injury repair. Resuscitative endovascular balloon occlusion of the aorta (REBOA) uses a minimally invasive, transfemoral balloon catheter, which is rapidly inserted retrograde and inflated for aortic occlusion, and may control inflow and allow time for hemostasis. We compared resuscitative thoracotomy with aortic cross-clamping (RT) with REBOA in trauma patients in profound hemorrhagic shock. METHODS Trauma registry data was used to compare all patients undergoing RT or REBOA during an 18-month period from two Level 1 trauma centers. RESULTS There was no difference between RT (n = 72) and REBOA groups (n = 24) in terms of demographics, mechanism of injury, or Injury Severity Scores (ISSs). There was no difference in chest and abdominal Abbreviated Injury Scale (AIS) scores between the groups. However, the RT patients had lower extremity AIS score as compared with REBOA patients (1.5 [0-3] vs. 4 [3-4], p < 0.001). Of the 72 RT patients, 45 (62.5%) died in the emergency department, 6 (8.3%) died in the operating room, and 14 (19.4%) died in the intensive care unit. Of the 24 REBOA patients, 4 (16.6%) died in the emergency department, 3 (12.5%) died in the operating room, and 8 (33.3%) died in the intensive care unit. In comparing location of death between the RT and REBOA groups, there were a significantly higher number of deaths in the emergency department among the RT patients as compared with the REBOA patients (62.5% vs. 16.7%, p < 0.001). REBOA had fewer early deaths and improved overall survival as compared with RT (37.5% vs. 9.7%, p = 0.003). CONCLUSION REBOA is feasible and controls noncompressible truncal hemorrhage in trauma patients in profound shock. Patients undergoing REBOA have improved overall survival and fewer early deaths as compared with patients undergoing RT. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Keene DD, Penn-Barwell JG, Wood PR, Hunt N, Delaney R, Clasper J, Russell RJ, Mahoney PF. Died of wounds: a mortality review. J ROY ARMY MED CORPS 2015; 162:355-360. [PMID: 26468431 DOI: 10.1136/jramc-2015-000490] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 09/21/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Combat casualty care is a complex system involving multiple clinicians, medical interventions and casualty transfers. Improving the performance of this system requires examination of potential weaknesses. This study reviewed the cause and timing of death of casualties deemed to have died from their injuries after arriving at a medical treatment facility during the recent conflicts in Iraq and Afghanistan, in order to identify potential areas for improving outcomes. METHODS This was a retrospective review of all casualties who reached medical treatment facilities alive, but subsequently died from injuries sustained during combat operations in Afghanistan and Iraq. It included all deaths from start to completion of combat operations. The UK military joint theatre trauma registry was used to identify cases, and further data were collected from clinical notes, postmortem records and coroner's reports. RESULTS There were 71 combat-related fatalities who survived to a medical treatment facility; 17 (24%) in Iraq and 54 (76%) in Afghanistan. Thirty eight (54%) died within the first 24 h. Thirty-three (47%) casualties died from isolated head injuries, a further 13 (18%) had unsurvivable head injuries but not in isolation. Haemorrhage following severe lower limb trauma, often in conjunction with abdominal and pelvic injuries, was the cause of a further 15 (21%) deaths. CONCLUSIONS Severe head injury was the most common cause of death. Irrespective of available medical treatment, none of this group had salvageable injuries. Future emphasis should be placed in preventative strategies to protect the head against battlefield trauma.
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Affiliation(s)
- Damian Douglas Keene
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | | | - P R Wood
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK Department of Anaesthesia, Queen Elizabeth Hospital, Birmingham, UK
| | - N Hunt
- Forensic Pathology Services Wantage, Oxon, UK
| | - R Delaney
- South West Group Practice, Bristol, UK
| | - J Clasper
- Centre for Blast Injury Studies, Imperial College, London, UK
| | - R J Russell
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - P F Mahoney
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK Centre for Blast Injury Studies, Imperial College, London, UK
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Prehospital use of hemostatic dressings by the Israel Defense Forces Medical Corps. J Trauma Acute Care Surg 2015; 79:S204-9. [DOI: 10.1097/ta.0000000000000720] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The traditional vs "1:1:1" approach debate on massive transfusion in trauma should not be treated as a dichotomy. Am J Emerg Med 2015; 33:1501-4. [PMID: 26184524 DOI: 10.1016/j.ajem.2015.06.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 06/22/2015] [Accepted: 06/25/2015] [Indexed: 11/21/2022] Open
Abstract
Traditional transfusion guidelines suggest that fresh frozen plasma (FFP) should be given based on laboratory or clinical evidence of coagulopathy or acute loss of 1 blood volume. This approach tends to result in a significant lag time between the first units of erythrocytes and FFP in trauma requiring massive transfusion. In severe trauma, observational studies have found an association between increased survival and aggressive use of FFP and platelets such that FFP:platelet:erythrocyte ratio approaches 1:1:1 to 2 from the first units of erythrocytes given. There are considerable concerns over either approach, and no randomized controlled trials have been published comparing the 2 approaches. Nowadays, trauma clinicans are incorporating the strenghts of both approaches and are no longer treating them as a dichotomy. Specifically, "1:1:1" proponents have devised 1:1:1 activation criteria to minimize unnecessary FFP and platelet transfusion and are prepared to deactivate the protocol as soon as patient is stabilized. Similarly, 1:1:1 skeptics are more mindful of the need to be proactive about trauma coagulopathy and the inherent delays in FFP administration in trauma patients.
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Klimo P, Ragel BT, Jones GM, McCafferty R. Severe Pediatric Head Injury During the Iraq and Afghanistan Conflicts. Neurosurgery 2015; 77:1-7; discussion 7. [DOI: 10.1227/neu.0000000000000743] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
AbstractBACKGROUND:Much has been written about injuries sustained by US and coalition soldiers during the Global War on Terrorism campaigns. However, injuries to civilians, including children, have been less well documented.OBJECTIVE:To describe the epidemiologic features and outcomes associated with isolated severe head injury in children during Operations Enduring Freedom and Iraqi Freedom (OEF and OIF).METHODS:A retrospective review of children (<18 years old) in the Joint Theater Trauma Registry with isolated head injury (defined as an Abbreviated Injury Score Severity Code >3) and treated at a US combat support hospital in Iraq or Afghanistan (2004–2012). The primary outcome was in-hospital mortality.RESULTS:We identified 647 children with severe isolated head injuries: 337 from OEF, 268 from OIF, and 42 nontheater specific. Most were boys (76%; median age = 8 years). Penetrating injuries were most common (60.6%). Overall, 330 (51%) children underwent a craniotomy/craniectomy; 156 (24.1%) succumbed to their injuries. Admission Glasgow Coma Score was predictive of survival among the entire cohort and each of the individual conflicts. Male sex also significantly increased the odds of survival for the entire group and OEF, but not for OIF. Closed-head injury improved the predictive ability of our model but did not reach statistical significance as an independent factor.CONCLUSION:This is the largest study of combat-related isolated head injuries in children. Admission Glasgow Coma Score and male sex were found to be predictive of survival. Assets to comprehensively care for the pediatric patient should be established early in future conflicts.
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Affiliation(s)
- Paul Klimo
- Semmes-Murphey Neurologic & Spine Institute, Memphis, Tennessee
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Brian T. Ragel
- Department of Neurosurgery, Mercy Hospital and Clinic, Springfield, Missouri
| | - G. Morgan Jones
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
- Department of Clinical Pharmacy, University of Tennessee Health Sciences Center, Memphis, Tennessee
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Bayır A, Eryılmaz M, Demirbilek M, Denkbaş EB, Arzıman I, Durusu M. Comparison of the topical haemostatic efficacy of nano-micro particles of clinoptilolite and kaolin in a rat model of haemorrhagic injury. Eur J Trauma Emerg Surg 2015; 42:77-86. [PMID: 26038025 DOI: 10.1007/s00068-015-0506-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE This study was designed to investigate if the potential haemostatic efficacy of gauze-impregnated clinoptilolite created with nano-technology is as strong as the widely used kaolin to control pulsatile arterial bleeding due to major vascular injury. METHODS 42 rats were separated into three groups of kaolin, clinoptilolite and control groups. The femoral artery was isolated and active arterial haemorrhage was performed. After 30 s of free arterial haemorrhage, compression was applied with a standard 100 g scale and haemostasis was assessed at the 1st, 3rd and 5th minutes. All groups were observed throughout 60 min for survival without any fluid resuscitation and the mean arterial pressure, pulse, body/surface temperature and arterial blood gas values were measured. RESULTS In the control group, haemostasis did not develop in any of the 12 rats and the survival rate was 5/12 (41.66 %). In the kaolin group, haemostasis developed in seven rats and of these, bleeding reoccurred in four. The survival rate was 10/13 (76.92 %). In the clinoptilolite group, haemostasis developed in eight rats and bleeding recurred in only one. The survival rate was 100 %. In terms of survival, the clinoptilolite and kaolin groups showed superiority to the control group (p = 0.002, p = 0.082). In the evaluation of recurrent haemorrhaging in the rats with haemostasis, clinoptilolite was observed to provide better coagulation than kaolin. CONCLUSION A statistically significant difference was determined in clinoptilolite and kaolin group, when they are separately compared with the control group in respect of the effect on MAP, HCO3 (-), lactate, base excess, haemostasis duration and survival rates. The effect of clinoptilolite on haemostasis and survival time was observed to be at least as good as that of kaolin; therefore, clinoptilolite can be used as an active ingredient in a topical haemostat.
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Affiliation(s)
- A Bayır
- Department of Emergency Medicine, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Selimiye Mh, Tıbbiye Cd, Üsküdar, 34668, Istanbul, Turkey.
| | - M Eryılmaz
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - M Demirbilek
- Department of Nanotechnology and Nanomedicine, University of Hacettepe, Ankara, Turkey
| | - E B Denkbaş
- Department of Nanotechnology and Nanomedicine, University of Hacettepe, Ankara, Turkey
| | - I Arzıman
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - M Durusu
- Department of Emergency Medicine, Gulhane Military Medical Academy, Ankara, Turkey
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Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg 2015; 77:852-8; discussion 858. [PMID: 25423534 DOI: 10.1097/ta.0000000000000443] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Early administration of tranexamic acid (TXA) has been associated with a reduction in mortality and blood product requirements in severely injured adults. It has also shown significantly reduced blood loss and transfusion requirements in major elective pediatric surgery, but no published data have examined the use of TXA in pediatric trauma. METHODS This is a retrospective review of all pediatric trauma admissions to the North Atlantic Treaty Organization Role 3 hospital, Camp Bastion, Afghanistan, from 2008 to 2012. Univariate and logistic regression analyses of all patients and select subgroups were performed to identify factors associated with TXA use and mortality. Standard adult dosing of TXA was used in all patients. RESULTS There were 766 injured patients 18 years or younger (mean [SD] age, 11 [5] years; 88% male; 73% penetrating injury; mean [SD], Injury Severity Score [ISS], 10 [9]; mean [SD] Glasgow Coma Scale [GCS] score, 12 [4]). Of these patients, 35% required transfusion in the first 24 hours, 10% received massive transfusion, and 76% required surgery. Overall mortality was 9%. Of the 766 patients, 66 (9%) received TXA. The only independent predictors of TXA use were severe abdominal or extremity injury (Abbreviated Injury Scale [AIS] score ≥ 3) and a base deficit of greater than 5 (all p < 0.05). Patients who received TXA had greater injury severity, hypotension, acidosis, and coagulopathy versus the patients in the no-TXA group. After correction for demographics, injury type and severity, vitals, and laboratory parameters, TXA use was independently associated with decreased mortality among all patients (odds ratio, 0.3; p = 0.03) and showed similar trends for subgroups of severely injured (ISS > 15) and transfused patients. There was no significant difference in thromboembolic complications or other cardiovascular events. Propensity analysis confirmed the TXA-associated survival advantage and suggested significant improvements in discharge neurologic status as well as decreased ventilator dependence. CONCLUSION TXA was used in approximately 10% of pediatric combat trauma patients, typically in the setting of severe abdominal or extremity trauma and metabolic acidosis. TXA administration was independently associated with decreased mortality. There were no adverse safety- or medication-related complications identified. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Henkelman S, Noorman F, Badloe JF, Lagerberg JWM. Utilization and quality of cryopreserved red blood cells in transfusion medicine. Vox Sang 2014; 108:103-12. [PMID: 25471135 DOI: 10.1111/vox.12218] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 09/18/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023]
Abstract
Cryopreserved (frozen) red blood cells have been used in transfusion medicine since the Vietnam war. The main method to freeze the red blood cells is by usage of glycerol. Although the usage of cryopreserved red blood cells was promising due to the prolonged storage time and the limited cellular deterioration at subzero temperatures, its usage have been hampered due to the more complex and labour intensive procedure and the limited shelf life of thawed products. Since the FDA approval of a closed (de) glycerolization procedure in 2002, allowing a prolonged postthaw storage of red blood cells up to 21 days at 2-6°C, cryopreserved red blood cells have become a more utilized blood product. Currently, cryopreserved red blood cells are mainly used in military operations and to stock red blood cells with rare phenotypes. Yet, cryopreserved red blood cells could also be useful to replenish temporary blood shortages, to prolong storage time before autologous transfusion and for IgA-deficient patients. This review describes the main methods to cryopreserve red blood cells, explores the quality of this blood product and highlights clinical settings in which cryopreserved red blood cells are or could be utilized.
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Affiliation(s)
- S Henkelman
- Department of Biomedical Engineering, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Inkinen J, Kirjasuo K, Gunn J, Kuttila K. Penetrating trauma; experience from Southwest Finland between 1997 and 2011, a retrospective descriptive study. Eur J Trauma Emerg Surg 2014; 41:429-33. [DOI: 10.1007/s00068-014-0445-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 09/01/2014] [Indexed: 11/30/2022]
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Gonsaga RAT, Valiatti JLDS, Brugugnolli ID, Gilioli JP, Valiatti MF, Neves N, Sertorio ND, Fraga GP. Evaluation of gasometric parameters in trauma patients during mobile prehospital care. Rev Col Bras Cir 2014; 40:293-9. [PMID: 24173479 DOI: 10.1590/s0100-69912013000400007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Accepted: 10/20/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate gasometric differences of severe trauma patients requiring intubation in prehospital care. METHODS Patients requiring airway management were submitted to collection of arterial blood samples at the beginning of pre-hospital care and at arrival at the Emergency Room. We analyzed: Glasgow Coma Scale, respiratory rate, arterial pH, arterial partial pressure of CO2 (PaCO2), arterial partial pressure of O2 (PaO2), base excess (BE), hemoglobin O2 saturation (SpO2) and the relation of PaO2 and inspired O2 (PaO2/FiO2). RESULTS There was statistical significance of the mean differences between the data collected at the site of the accident and at the entrance of the ER as for respiratory rate (p = 0.0181), Glasgow Coma Scale (p = 0.0084), PaO2 (p <0.0001) and SpO2 (p = 0.0018). CONCLUSION tracheal intubation changes the parameters PaO2 and SpO2. There was no difference in metabolic parameters (pH, bicarbonate and base excess). In the analysis of blood gas parameters between survivors and non-survivors there was statistical difference between PaO2, hemoglobin oxygen saturation and base excess.
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Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, Zhang M. Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis. Scand J Trauma Resusc Emerg Med 2014; 22:54. [PMID: 25178942 PMCID: PMC4347587 DOI: 10.1186/s13049-014-0054-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 08/25/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction The purpose of this meta-analysis was to explore the value of whole-body computed tomography (WBCT) in major trauma patients (MTPs). Methods A comprehensive search for articles from Jan 1, 1980 to Dec 31, 2013 was conducted through PubMed, Cochrane Library database, China biology medical literature database, Web of knowledge, ProQuest, EBSCO, OvidSP, and ClinicalTrials.gov. Studies which compared whole-body CT with conventional imaging protocol (X-ray of the pelvis and chest, trans-abdominal sonography, and/or selective CT) in MTPs were eligible. The primary endpoint was all-cause mortality. The second endpoints included: time spent in the emergency department (ED), the duration of mechanical ventilation, ICU and hospital length of stay (LOS), the incidence of Multiple Organ Dysfunction Syndrome (MODS) /Multiple Organ Failure (MOF). Analysis was performed with Review Manager 5.2.10 and Stata 12.0. Results Eleven trials enrolling 26371 patients were analyzed. In MTPs, the application of WBCT was associated with lower mortality rate (pooled OR: 0.66, 95% CI: 0.52 to 0.85) and a shorter stay in the ED (weighted mean difference (WMD), −27.58 min; 95% CI, −43.04 to −12.12]. There was no effect of WBCT on the length of ICU stay (WMD, 0.95 days; 95% CI: −0.08 to 1.98) and the length of hospital stay (WMD, 0.56 days; 95% CI: −0.03 to 1.15). Patients in the WBCT group had a longer duration of mechanical ventilation (WMD, 0.96 days, 95% CI: 0.32 to 1.61) and higher incidence of MODS/MOF (OR, 1.44, 95% CI: 1.35-1.54; P = 0.00001). Conclusions The present meta-analysis suggests that the application of whole-body CT significantly reduces the mortality rate of MTPs and markedly reduces the time spent in the emergency department.
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Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Yuefeng Ma
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Shouyin Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Ligang Ye
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Zhongjun Zheng
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Yongan Xu
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
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Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course: curriculum development, content validation, and program assessment. J Trauma Acute Care Surg 2014; 76:929-35; discussion 935-6. [PMID: 24662854 DOI: 10.1097/ta.0000000000000164] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of hemorrhage shock requires support of central aortic pressure including perfusion to the brain and heart as well as measures to control bleeding. Emerging endovascular techniques including resuscitative endovascular balloon occlusion of the aorta serve as potential lifesaving adjuncts in this setting. The Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course was developed to provide fundamental endovascular training for trauma surgeons. METHODS ESTARS 2-day course incorporated pretest/posttest examinations, precourse materials, lectures, endovascular and open vascular instruments, Vascular Intervention System Trainer endovascular simulator, and live animal laboratories for training and testing. Curriculum included endovascular techniques for trauma; review of wires, sheaths, and catheters; as well as regional vascular injury management. Animal laboratories integrated arterial access, angiography, coil embolization, resuscitative endovascular balloon occlusion of the aorta, control of iliac artery injury, and vascular shunt placement. Students completed a knowledge test (precourse/postcourse) and a summative skills assessment. The test measured knowledge and judgment in vascular injury management as defined in the course objectives. Vascular Intervention System Trainer and animal laboratory were used for final examinations. Subjective performance was graded by expert observers using a global assessment scale and performance metrics. RESULTS Four pilot ESTARS courses were completed, with four participants each. Knowledge and performance significantly improved after ESTARS. Mean test examination scores increased by 77% to 85%, with a mean change of 9 percentage points [paired t (15) = 7.82, p < 0.0001]. The test was unidimensional (Cronbach's α = 0.67). Technical skill significantly improved for both endovascular simulation and live animal laboratory examinations. All participants passed the live animal laboratory practical examination. CONCLUSION The ESTARS curriculum is effective at teaching a basic set of endovascular skills for resuscitation and hemorrhage control to trauma surgeons. ESTARS was confirmed as a stepwise and hierarchical curriculum demonstrating measurable improvements in performance metrics and should serve as a model for future competency-based structured training in endovascular trauma skills.
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Palmer L, Martin L. Traumatic coagulopathy--part 2: Resuscitative strategies. J Vet Emerg Crit Care (San Antonio) 2014; 24:75-92. [PMID: 24393363 DOI: 10.1111/vec.12138] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 11/10/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To discuss the current resuscitative strategies for trauma-induced hemorrhagic shock and acute traumatic coagulopathy (ATC). ETIOLOGY Hemorrhagic shock can be acutely fatal if not immediately and appropriately treated. The primary tenets of hemorrhagic shock resuscitation are to arrest hemorrhage and restore the effective circulating volume. Large volumes of isotonic crystalloids have been the resuscitative strategy of choice; however, data from experimental animal models and retrospective human analyses now recognize that large-volume fluid resuscitation in uncontrolled hemorrhage may be deleterious. The optimal resuscitative strategy has yet to be defined. In human trauma, implementing damage control resuscitation with damage control surgery for controlling ongoing hemorrhage, acidosis, and hypothermia; managing ATC; and restoring effective circulating volume is emerging as a more optimal resuscitative strategy. With hyperfibrinolysis playing an integral role in the manifestation of ATC, the use of antifibrinolytics (eg, tranexamic acid and aminocaproic acid) may also serve a beneficial role in the early posttraumatic period. Considering the sparse information regarding these resuscitative techniques in veterinary medicine, veterinarians are left with extrapolating information from human trials and experimental animal models. DIAGNOSIS Viscoelastic tests integrated with predictive scoring systems may prove to be the most reliable methods for early detection of ATC as well as for guiding transfusion requirements. SUMMARY Hemorrhage accounts for up to 40% of human trauma-related deaths and remains the leading cause of preventable death in human trauma. The exact proportion of trauma-related deaths due to exsanguinations in veterinary patients remains uncertain. Survivability depends upon achieving rapid definitive hemostasis, early attenuation of posttraumatic coagulopathy, and timely restoration of effective circulating volume. Early institution of damage control resuscitation in severely injured patients with uncontrolled hemorrhage has the ability to curtail posttraumatic coagulopathy and the exacerbation of metabolic acidosis and hypothermia and improve survival until definitive hemostasis is achieved.
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Affiliation(s)
- Lee Palmer
- Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, Auburn, AL 36849
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Réanimation initiale sur le champ de bataille: principaux éléments de prise en charge selon le service de santé des armées français. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0824-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Combat casualties undergoing lifesaving interventions have decreased heart rate complexity at multiple time scales. J Crit Care 2013; 28:1093-8. [PMID: 24140167 DOI: 10.1016/j.jcrc.2013.08.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/23/2013] [Accepted: 08/30/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE We found that heart rate (HR) complexity metrics such as sample entropy (SampEn) identified patients with trauma receiving lifesaving interventions (LSIs). We now aimed (1) to test a multiscale entropy (MSE) index, (2) to compare it to single-scale measures including SampEn, and (3) to assess different parameter values for calculation of SampEn and MSE. METHODS This was a study of combat casualties in an emergency department in Iraq. Electrocardiograms of 70 acutely injured adults were recorded. Twelve underwent LSIs and 58 did not. Lifesaving interventions included endotracheal intubation (9), tube thoracostomy (9), and emergency transfusion (4). From each electrocardiogram, a segment of 800 consecutive beats was selected. Offline, R waves were detected and R-to-R interval time series were generated. Sample entropy, MSE, and time-domain measures of HR variability (mean HR, SD, the proportion of pairs of consecutive NN intervals that differ by more than 20 and 50 milliseconds, square root of the mean of the squares of differences between adjacent NN intervals) were computed. RESULTS Differences in mean HR (LSI: 111 ± 33, non-LSI: 90 ± 17 beats/min) were not significant. Systolic arterial pressure was statistically but not clinically different (LSI: 123 ± 19, non-LSI: 135 ± 19 mm Hg). Sample entropy (LSI: 0.90 ± 0.42, non-LSI: 1.19 ± 0.35; P < .05) and MSE index (LSI: 2.58 ± 2.55, non-LSI: 5.67 ± 2.48; P < .001) differed significantly. CONCLUSIONS Complexity of HR dynamics over a range of time scales was lower in high-risk than in low-risk combat casualties and outperformed traditional vital signs.
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