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Lahvic NK, Schauer SG, Higgins SS, Johannigman JA, Grathwohl KW. An Analysis of the Association of Arrival Hemoglobin With Overtransfusion at 24 Hours in a Trauma Population. Mil Med 2024:usae293. [PMID: 38913448 DOI: 10.1093/milmed/usae293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/20/2024] [Accepted: 06/10/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Hemorrhage control and resuscitative concepts have evolved in recent years, leading to aggressive use of blood products in trauma patients. There is subsequently a potential risk for overtransfusion, adverse effects, and waste associated with unnecessary transfusion. Methods for conserving blood products are of particular importance in future large-scale combat operations where supply chains are likely to be strained. This study examined the association of emergency department (ED) arrival hemoglobin (HGB) with overtransfusion among survivors at 24 hours after major trauma at a military trauma center. MATERIALS AND METHODS We performed a retrospective cohort study of patients who had a "major trauma" activation and received any red blood cells. Overtransfusion was defined as a HGB level ≥11.0 g/dL at 24 hours (outcome variable). Multivariable logistic regression statistics were used to compare groups and adjust for confounders (injury severity score, arrival modified shock index, injury type, age, and gender). A receiver operating characteristic was constructed with overtransfusion at 24 hours as the outcome (binary) and arrival HGB (continuous) as the independent variable. RESULTS A total of 382 patients met inclusion criteria. Overtransfusion occurred in 30.4% (n = 116) of patients, with mean ED HGB levels of 13.2 g/dL (12.9 to 13.6) versus 11.6 g/dL (11.3 to 11.8, P < .001). Receiver operating characteristic analysis showed that ED HGB was highly sensitive (0.931) for predicting 24-hour overtransfusion. In our multivariable logistic regression analysis, when adjusting for injury severity score, arrival modified shock index, injury type, age, and gender, we found that the ED HGB value had a per-unit odds ratio of 1.60 (95% CI, 1.38 to 1.86) for 24-hour overtransfusion. Hospital and intensive care unit length of stay, mechanical ventilator days, and mortality did not increase. CONCLUSION We found that the arrival HGB value was associated with overtransfusion among 24-hour survivors in a civilian trauma setting. Our findings will inform future prospective studies that investigate blood sparing clinical practice guidelines.
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Affiliation(s)
| | - Steven G Schauer
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Sophie S Higgins
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | | | - Kurt W Grathwohl
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
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2
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Kosaki Y, Hongo T, Hayakawa M, Kudo D, Kushimoto S, Tagami T, Naito H, Nakao A, Yumoto T. Association of initial lactate levels and red blood cell transfusion strategy with outcomes after severe trauma: a post hoc analysis of the RESTRIC trial. World J Emerg Surg 2024; 19:1. [PMID: 38167057 PMCID: PMC10763143 DOI: 10.1186/s13017-023-00530-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The appropriateness of a restrictive transfusion strategy for those with active bleeding after traumatic injury remains uncertain. Given the association between tissue hypoxia and lactate levels, we hypothesized that the optimal transfusion strategy may differ based on lactate levels. This post hoc analysis of the RESTRIC trial sought to investigate the association between transfusion strategies and patient outcomes based on initial lactate levels. METHODS We performed a post hoc analysis of the RESTRIC trial, a cluster-randomized, crossover, non-inferiority multicenter trials, comparing a restrictive and liberal red blood cell transfusion strategy for adult trauma patients at risk of major bleeding. This was conducted during the initial phase of trauma resuscitation; from emergency department arrival up to 7 days after hospital admission or intensive care unit (ICU) discharge. Patients were grouped by lactate levels at emergency department arrival: low (< 2.5 mmol/L), middle (≥ 2.5 and < 4.0 mmol/L), and high (≥ 4.0 mmol/L). We compared 28 days mortality and ICU-free and ventilator-free days using multiple linear regression among groups. RESULTS Of the 422 RESTRIC trial participants, 396 were analyzed, with low (n = 131), middle (n = 113), and high (n = 152) lactate. Across all lactate groups, 28 days mortality was similar between strategies. However, in the low lactate group, the restrictive approach correlated with more ICU-free (β coefficient 3.16; 95% CI 0.45 to 5.86) and ventilator-free days (β coefficient 2.72; 95% CI 0.18 to 5.26) compared to the liberal strategy. These findings persisted even after excluding patients with severe traumatic brain injury. CONCLUSIONS Our results suggest that restrictive transfusion strategy might not have a significant impact on 28-day survival rates, regardless of lactate levels. However, the liberal transfusion strategy may lead to shorter ICU- and ventilator-free days for patients with low initial blood lactate levels.
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Affiliation(s)
- Yoshinori Kosaki
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takashi Hongo
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, N14W5 Kita-ku, Sapporo, 060-8648, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, 1-396 Kosugimachi, Nakahara-ku, Kawasaki, Kanagawa, 211-8533, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Faculty of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
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3
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Lassila R, Weisel JW. Role of red blood cells in clinically relevant bleeding tendencies and complications. J Thromb Haemost 2023; 21:3024-3032. [PMID: 37210074 PMCID: PMC10949759 DOI: 10.1016/j.jtha.2023.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/20/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023]
Abstract
The multiple roles of red blood cells (RBCs) are often neglected as contributors in hemostasis and thrombosis. Proactive opportunities to increase RBC numbers, either acutely or subacutely in the case of iron deficiency, are critical as RBCs are the cellular elements that initiate hemostasis together with platelets and stabilize fibrin and clot structure. RBCs also possess several functional properties to assist hemostasis: releasing platelet agonists, promoting shear force-induced von Willebrand factor unfolding, procoagulant capacity, and binding to fibrin. Additionally, blood clot contraction is important to compress RBCs to form a tightly packed array of polyhedrocytes, making an impermeable seal for hemostasis. All these functions are important for patients having intrinsically poor capacity to cease bleeds (ie, hemostatic disorders) but, conversely, can also play a role in thrombosis if these RBC-mediated reactions overshoot. One acquired example of bleeding with anemia is in patients treated with anticoagulants and/or antithrombotic medication because upon initiation of these drugs, baseline anemia doubles the risk of bleeding complications and mortality. Also, anemia is a risk factor for reoccurring gastrointestinal and urogenital bleeds, pregnancy, and delivery complications. This review summarizes the clinically relevant properties and profiles of RBCs at various steps of platelet adhesion, aggregation, thrombin generation, and fibrin formation, including both structural and functional elements. Regarding patient blood management guidelines, they support minimizing transfusions, but this approach does not deal with severe inherited and acquired bleeding disorders where a poor hemostatic propensity is exacerbated by limited RBC availability, for which future guidance will be needed.
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Affiliation(s)
- Riitta Lassila
- Research Program Unit in Systems Oncology, Oncosys, Medical Faculty, University of Helsinki, Helsinki, Finland; Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital, Helsinki, Finland.
| | - John W Weisel
- Department of Cell and Developmental Biology, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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4
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 115] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department 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
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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The diagnostic value of laboratory tests in detecting solid organ injuries in pediatric patients with blunt abdominal trauma: A prospective, observational study. Am J Emerg Med 2022; 57:133-137. [DOI: 10.1016/j.ajem.2022.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/23/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
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Rungsinaporn V, Akkarawanit P, Kongmalai P. Benefits of early application of pelvic circumferential compression device to reduce bleeding in pelvic fractures. BMC Musculoskelet Disord 2022; 23:203. [PMID: 35241032 PMCID: PMC8892740 DOI: 10.1186/s12891-022-05166-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 03/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background To study of efficacy of early pelvic circumferential compression device using in patients with suspected pelvic trauma, compared with conventional stepwise approach. Methods Traumatic injury and at least one of the following criteria are required for inclusion: loss of consciousness or a Glasgow coma score (GCS) of less than 13; systolic blood pressure less than 90 mmHg; falling from more than 6 m; injury to several important organs; and a positive pelvic compression test. Patients who satisfied the inclusion criteria for the experimental group were given an early application of a commercial pelvic sling beginning in July 2019. The control group consisted of cases who got the device after clinical or radiological confirmation of a pelvic fracture in the previous year. Gender, age, mechanism of injury, GCS, hospital stay, amount of packed red blood cell transfusion, hematocrit in emergency room, and hematocrit 24 h after application of pelvic binder were all assessed and compared. Results The study had a total of 30 participants, with 15 in each group. The number of packed red blood cell transfusions in the early pelvic binder group (0.80 ± 1.42) is considerably lower than in the control group (2.4 ± 2.32) (P = 0.008), although the hematocrit change is not statistically different between the groups (2.1 VS 0.7) (P = 0.191). The time it took to install a pelvic binder was considerably shorter in the early pelvic binder group (16.40 ± 5.45) than in the control group (40.40 ± 13.64) (P = 0.001). There were no problems associated to soft tissue and skin necrosis in either group of patients. Conclusions The use of the PCCD for 24 h prior to clinical and radiographic confirmation has significantly reduced the rate of packed red blood cell transfusion in any pelvic fracture patient without device-related complications. Trial registration The study was entered into the Thai Clinical Trials Registry (TCTR20210809007).
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Affiliation(s)
- Visit Rungsinaporn
- Department of Orthopaedics, Faculty of Medicine, Srinakharinwirot University, 62 Moo 7, Rangsit-Nakhon Nayok Road, Ongkharak, Nakhon Nayok, 26120, Thailand
| | - Pawin Akkarawanit
- Department of Orthopaedics, Faculty of Medicine, Srinakharinwirot University, 62 Moo 7, Rangsit-Nakhon Nayok Road, Ongkharak, Nakhon Nayok, 26120, Thailand
| | - Pinkawas Kongmalai
- Department of Orthopaedics, Faculty of Medicine, Srinakharinwirot University, 62 Moo 7, Rangsit-Nakhon Nayok Road, Ongkharak, Nakhon Nayok, 26120, Thailand.
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Kawai Y, Fukushima H, Asai H, Takano K, Okuda A, Tada Y, Maegawa N, Bolstad F. Significance of initial hemoglobin levels in severe trauma patients without prehospital fluid administration: a single-center study in Japan. Trauma Surg Acute Care Open 2021; 6:e000831. [PMID: 35036573 PMCID: PMC8720982 DOI: 10.1136/tsaco-2021-000831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/14/2021] [Indexed: 11/28/2022] Open
Abstract
Objectives Hemoglobin (Hb) levels have been considered to remain stable in the early stages of bleeding due to trauma. However, several studies have reported that rapid compensatory fluid shifts cause Hb dilution earlier than previously thought. These reports are from Western countries where it is standard protocol to administer fluids during an emergency, making it almost impossible to eliminate the effect of prehospital intravenous fluid administration on Hb levels. This study aimed to determine the relationship between Hb levels and severity of injury on arrival at the hospital in severe trauma patients without prehospital intravenous fluid administration. Methods This single-center observational retrospective study included patients with Abbreviated Injury Scale scores of 3 or above between 2008 and 2014. In Japan, prehospital life-saving technicians were not allowed to administer intravenous fluids until 2014. We investigated whether the difference between the measured blood Hb level at arrival and the corresponding standard blood Hb level for each age group and sex reported in the national survey was associated with the severity of injury and the need for hemostasis. Results In total, 250 patients were included in this study (median age, 46 years; male patients, 183). The median time from injury to arrival at the hospital was 45 min, and there was no statistical correlation with the initial Hb level on arrival (ρ=0.092, p=0.14). When the study subjects were stratified into four groups according to the initial Hb levels, lower Hb levels correlated with higher rates of requirement for hemostatic interventions (p=0.02) and mortality (p=0.02). In addition, lower Hb levels were associated with the need for hemostasis. Conclusion In severe trauma patients without prehospital intravenous fluid administration, decreased Hb levels on arrival may be associated with the severity of trauma and with the need for hemostasis. Level of evidence Level IV.
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Affiliation(s)
- Yasuyuki Kawai
- Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hidetada Fukushima
- Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hideki Asai
- Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Keisuke Takano
- Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Akinori Okuda
- Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Yusuke Tada
- Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Naoki Maegawa
- Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Nara, Japan
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Clinical and laboratory parameters in blunt pelvic trauma not associated with subsequent positive conventional angiography in patients with positive CTA. Emerg Radiol 2021; 28:557-563. [PMID: 33428045 DOI: 10.1007/s10140-020-01888-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/14/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE This study evaluates clinical and laboratory parameters, as well as extravasation and hematoma size on CTA as potential predictors of conventional angiogram (CA) results. METHODS This is a retrospective study of 380 adult patients presenting with pelvic trauma over a 9-year period. Of these patients, 91 were found to have active arterial extravasation on initial CTA. Statistical analysis between the two groups +CA versus -CA was performed to determine whether clinical and laboratory parameters, as well as extravasation size and hematoma size could predict CA results. RESULTS There were no significant differences in all clinical and laboratory data, including hemodynamic instability (defined as systolic blood pressure < 90 mmHg) on presentation (22.2% vs. 21.4%), except for Glasgow Coma Scale (p = 0.015) when comparing the two groups. Extravasation size and hematoma size as continuous or categorical variables were not predictive of subsequent positive CA. Secondary analysis demonstrated no association between select parameters (i.e., hematocrit, systolic blood pressure, and lactate) and subsequent positive CA while controlling for extravasation size or hematoma size. CONCLUSION Clinical and laboratory parameters in blunt pelvic trauma with arterial hemorrhage were not significantly associated with subsequent conventional angiography results, once accounting for degree of hemorrhage. The area of the foci of active extravasation and hematoma size in the axial plane were not significantly associated with the need for embolization. We conclude from these findings that catheter angiography should be considered in patients with blunt pelvic trauma found to have active arterial extravasation, regardless of size of bleed or the patient's clinical or laboratory values.
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Park SM, Visbal-Onufrak MA, Haque MM, Were MC, Naanyu V, Hasan MK, Kim YL. mHealth spectroscopy of blood hemoglobin with spectral super-resolution. OPTICA 2020; 7:563-573. [PMID: 33365364 PMCID: PMC7755164 DOI: 10.1364/optica.390409] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/01/2020] [Indexed: 05/05/2023]
Abstract
Although blood hemoglobin (Hgb) testing is a routine procedure in a variety of clinical situations, noninvasive, continuous, and real-time blood Hgb measurements are still challenging. Optical spectroscopy can offer noninvasive blood Hgb quantification, but requires bulky optical components that intrinsically limit the development of mobile health (mHealth) technologies. Here, we report spectral super-resolution (SSR) spectroscopy that virtually transforms the built-in camera (RGB sensor) of a smartphone into a hyperspectral imager for accurate and precise blood Hgb analyses. Statistical learning of SSR enables us to reconstruct detailed spectra from three color RGB data. Peripheral tissue imaging with a mobile application is further combined to compute exact blood Hgb content without a priori personalized calibration. Measurements over a wide range of blood Hgb values show reliable performance of SSR blood Hgb quantification. Given that SSR does not require additional hardware accessories, the mobility, simplicity, and affordability of conventional smartphones support the idea that SSR blood Hgb measurements can be used as an mHealth method.
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Affiliation(s)
- Sang Mok Park
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana 47907, USA
| | | | - Md Munirul Haque
- R. B. Annis School of Engineering, University of Indianapolis, Indianapolis, Indiana 46227, USA
| | - Martin C. Were
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee 37212, USA
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37212, USA
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA
| | - Violet Naanyu
- Department of Behavioral Sciences, Moi University School of Medicine, Eldoret, Kenya
| | - Md Kamrul Hasan
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee 37212, USA
| | - Young L. Kim
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana 47907, USA
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, Indiana 47907, USA
- Purdue University Center for Cancer Research, Purdue University, West Lafayette, Indiana 47907, USA
- Purdue Quantum Center, Purdue University, West Lafayette, Indiana 47907, USA
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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: 688] [Impact Index Per Article: 137.6] [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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11
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Figueiredo S, Taconet C, Harrois A, Hamada S, Gauss T, Raux M, Duranteau J. How useful are hemoglobin concentration and its variations to predict significant hemorrhage in the early phase of trauma? A multicentric cohort study. Ann Intensive Care 2018; 8:76. [PMID: 29980953 PMCID: PMC6035120 DOI: 10.1186/s13613-018-0420-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/21/2018] [Indexed: 12/15/2022] Open
Abstract
Background The diagnostic value of hemoglobin (Hb) for detecting a significant hemorrhage (SH) in the early phase of trauma remains controversial. The present study aimed to assess the abilities of Hb measurements taken at different times throughout trauma management to identify patients with SH. Methods All consecutive adult trauma patients directly admitted to six French level-1 trauma centers with at least one prehospital Hb measurement were analyzed. The abilities of the following variables to identify SH (≥ 4 units of red blood cells in the first 6 h and/or death related to uncontrolled bleeding within 24 h) were determined and compared to that of shock index (SI): Hb as measured with a point-of-care (POC) device by the prehospital team on scene (POC-Hbprehosp) and upon patient’s admission to the hospital (POC-Hbhosp), the difference between POC-Hbhosp and POC-Hbprehosp (DeltaPOC-Hb) and Hb as measured by the hospital laboratory on admission (Hb-Labhosp). Results A total of 6402 patients were included, 755 with SH and 5647 controls (CL). POC-Hbprehosp significantly predicted SH with an area under ROC curve (AUC) of 0.72 and best cutoff values of 12 g/dl for women and 13 g/dl for men. POC-Hbprehosp < 12 g/dl had 90% specificity to predict of SH. POC-Hbhosp and Hb-Labhosp (AUCs of 0.92 and 0.89, respectively) predicted SH better than SI (AUC = 0.77, p < 0.001); best cutoff values of POC-Hbhosp were 10 g/dl for women and 12 g/dl for men. DeltaPOC-Hb also predicted SH with an AUC of 0.77, a best cutoff value of − 2 g/dl irrespective of the gender. For a same prehospital fluid volume infused, DeltaPOC-Hb was significantly larger in patients with significant hemorrhage than in controls. Conclusions Challenging the classical idea that early Hb measurement is not meaningful in predicting SH, POC-Hbprehosp was able, albeit modestly, to predict significant hemorrhage. POC-Hbhosp had a greater ability to predict SH when compared to shock index. For a given prehospital fluid volume infused, the magnitude of the Hb drop was significantly higher in patients with significant hemorrhage than in controls. Electronic supplementary material The online version of this article (10.1186/s13613-018-0420-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Figueiredo
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France. .,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France.
| | - C Taconet
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
| | - A Harrois
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
| | - S Hamada
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
| | - T Gauss
- Department of Anaesthesia and Critical Care, Beaujon Hospital, Hôpitaux Universitaires Paris-Nord Val-de-Seine, Assistance Publique - Hôpitaux de Paris, Clichy, France
| | - M Raux
- SSPI - Accueil des Polytraumatisés, Hôpital Universitaire Pitié Salpêtrière - Charles Foix, Assistance Publique - Hôpitaux de Paris, Paris, France.,INSERM UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Université Pierre et Marie Curie, Paris, France
| | - J Duranteau
- Department of Anaesthesia and Critical Care, Assistance Publique - Hôpitaux de Paris, Hôpital Bicêtre, University Paris-Sud, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.,Hôpitaux Universitaires Paris Sud, 94275, Le Kremlin Bicêtre, France
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12
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Bhandarkar P, Pal R, Munivenkatappa A, Roy N, Kumar V, Agrawal A. Distribution of Laboratory Parameters in Trauma Population. J Emerg Trauma Shock 2018; 11:10-14. [PMID: 29628663 PMCID: PMC5852909 DOI: 10.4103/jets.jets_70_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background: Biochemical laboratory investigations help plan optimum management and communication in short- as well as long-term outcome to trauma victims. Objective: To assess the status of real-time values of biochemical laboratory investigations of different trauma patients and their association with overall mortality. Materials and Methods: Data based on prospective, observational registry of “Towards Improved Trauma Care Outcomes” (TITCO) from four Indian city hospitals. Hemoglobin, hematocrit, random blood sugar, blood urea nitrogen (BUN), and serum creatinine of patients on admission were recorded. Logistic regression was applied with all biochemical investigation as independent variable and overall mortality as dependent variable. Results: Among 17047 trauma patients, 3456 with available laboratory result details were considered for this study. Overall mortality was 20% (range 14%–21%). For the higher laboratory results, value mortality was 21%–70%, with highest death (70%) for higher hemoglobin patients, followed by hematocrit (44%) and then creatinine (43%). Odds of high hemoglobin compared to normal were 15.20; odds of higher and lower of normal creatinine were 3.80 and 1.65 and for BUN were 2.17 and 1.92, respectively. Gender-wise significant difference was in overall female mortality (29%)% compared males (18%). Similar differences were replicated with results of each laboratory tests. Conclusion: The study ascertained the composite additional explanatory values of laboratory parameters in predicting outcome among injured patients in our population from Indian settings.
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Affiliation(s)
- Prashant Bhandarkar
- Department of Statistics, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | - Ranabir Pal
- Department of Community Medicine, ESIC Medical College and Hospital, Faridabad, Haryana, India
| | - Ashok Munivenkatappa
- VDRL Project, National Institute of Epidemiology (ICMR), Chennai, Tamil Nadu, India
| | - Nobhojit Roy
- Department of Surgery, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
| | - Amit Agrawal
- Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
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13
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Khalfaoui MY, Godavitarne C, Wilkinson MCP. Optimal Timing for Hemoglobin Concentration Determination after Total Knee Arthroplasty: Day 1 versus Day 2. Knee Surg Relat Res 2017; 29:52-56. [PMID: 28231649 PMCID: PMC5336371 DOI: 10.5792/ksrr.16.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 09/28/2016] [Accepted: 09/29/2016] [Indexed: 10/24/2022] Open
Abstract
Purpose Postoperative hemoglobin (Hb) determination remains an essential parameter for quantifying blood loss following total knee replacement (TKR) surgery and guiding transfusion practice. In this study we aimed to ascertain the optimal timing for Hb determination postoperatively and assess its relationship to serum hematocrit (Hct). Materials and Methods This was a retrospective cohort analysis of 61 consecutive patients undergoing preoperative, day 1 and day 2 Hb and Hct concentration determination following TKR surgery. This was a single centre study in the United Kingdom. Results The mean fall in Hb concentration at day 1 was 2.9 g/dL in comparison to 3.3 g/dL at day 2. This indicated a significant difference of 0.39 g/dL (p=0.023). A total of 5 patients required blood transfusions following day 2 Hb determination. Postoperative Hct values varied in close relation with the Hb concentration with no significant differences demonstrated. Our study reveals a significant change between day 1 and day 2 Hb concentrations following TKR surgery, with no significant differing information provided through Hct determination. Conclusions Our results support the use of delayed routine testing at day 2 following surgery as it is likely to more accurately reflect ongoing hidden blood loss into the joint cavity and within soft tissue planes.
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14
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When Should Abdominal Computed Tomography Be Considered in Patients with Lower Rib Fractures? J Emerg Med 2016; 52:609-614. [PMID: 27979644 DOI: 10.1016/j.jemermed.2016.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 10/06/2016] [Accepted: 11/01/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Lower rib fractures are considered as a marker of intra-abdominal organ injury. Abdominal computed tomography (CT) is the "gold standard" examination for patients with lower rib fractures. However, the reported incidence of concomitant intra-abdominal injuries (IAI) is 20%-40%. OBJECTIVE The purpose of this study was to evaluate the incidence of intra-abdominal organ injuries in blunt trauma patients with lower rib fractures. METHODS Medical charts and radiology reports of patients with lower rib (from the 8th to 12th rib) fractures admitted to our center during a 6-year period were retrospectively reviewed. Patients were divided into two groups. Group I included patients with intra-abdominal injury (IAI) diagnosed either by CT or on urgent laparotomy, and Group II included those with normal abdominal CT scans. Data included demographics, mechanism of injury, laboratory tests, radiology results including number and location of fractured ribs, and incidence of IAI. RESULTS Overall 318 patients were included in the study. Fifty-seven patients (17.9%) had 71 IAIs compared with 265 (82.1%) patients with no IAI. Logistic regression identified age younger than 55 years (relative risk [RR] = 7.2; 95% confidence interval [CI] 3.1-16.8; p = 0.001), bilateral rib fractures (RR = 3.9; 95% CI 1.1-13.5; p = 0.03) and decreased levels of hematocrit (RR = 2.4; 95% CI 1.2-4.8; p = 0.016) as independent risk factors for the presence of IAI. CONCLUSIONS Abdominal CT should be considered in blunt trauma patients with lower rib fractures who are younger than 55 years of age and have bilateral rib fractures and decreased levels of hematocrit on admission.
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15
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16
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Oh WS, Chon SB. Calculation of the Residual Blood Volume after Acute, Non-Ongoing Hemorrhage Using Serial Hematocrit Measurements and the Volume of Isotonic Fluid Infused: Theoretical Hypothesis Generating Study. J Korean Med Sci 2016; 31:814-6. [PMID: 27134507 PMCID: PMC4835611 DOI: 10.3346/jkms.2016.31.5.814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 02/16/2016] [Indexed: 12/05/2022] Open
Abstract
Fluid resuscitation, hemostasis, and transfusion is essential in care of hemorrhagic shock. Although estimation of the residual blood volume is crucial, the standard measuring methods are impractical or unsafe. Vital signs, central venous or pulmonary artery pressures are inaccurate. We hypothesized that the residual blood volume for acute, non-ongoing hemorrhage was calculable using serial hematocrit measurements and the volume of isotonic solution infused. Blood volume is the sum of volumes of red blood cells and plasma. For acute, non-ongoing hemorrhage, red blood cell volume would not change. A certain portion of the isotonic fluid would increase plasma volume. Mathematically, we suggest that the residual blood volume after acute, non-ongoing hemorrhage might be calculated as 0·25N/[(Hct1/Hct2)-1], where Hct1 and Hct2 are the initial and subsequent hematocrits, respectively, and N is the volume of isotonic solution infused. In vivo validation and modification is needed before clinical application of this model.
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Affiliation(s)
- Won Sup Oh
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sung-Bin Chon
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
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17
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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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Transforming Hemoglobin Measurement in Trauma Patients: Noninvasive Spot Check Hemoglobin. J Am Coll Surg 2015; 220:93-8. [DOI: 10.1016/j.jamcollsurg.2014.09.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/09/2014] [Accepted: 09/25/2014] [Indexed: 11/20/2022]
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19
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Optimization of Oxygen Delivery in Fluid Resuscitation for Hemorrhagic Shock: A Computer Simulation Study. Cardiovasc Eng Technol 2013. [DOI: 10.1007/s13239-013-0169-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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20
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Shander A, Gross I, Hill S, Javidroozi M, Sledge S. A new perspective on best transfusion practices. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 11:193-202. [PMID: 23399354 PMCID: PMC3626470 DOI: 10.2450/2012.0195-12] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 10/25/2012] [Indexed: 01/08/2023]
Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
- Institute for Patient Blood Management and Bloodless Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
| | - Irwin Gross
- Department of Transfusion Services, Eastern Maine Medical Center, Bangor, Maine
| | - Steven Hill
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mazyar Javidroozi
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey
| | - Sharon Sledge
- Department of Patient Blood Management, Newark Beth Israel Medical Center, Newark, New Jersey, United States of America
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Thorson CM, Van Haren RM, Ryan ML, Pereira R, Olloqui J, Guarch GA, Barrera JM, Busko AM, Livingstone AS, Proctor KG. Admission hematocrit and transfusion requirements after trauma. J Am Coll Surg 2012. [PMID: 23177369 DOI: 10.1016/j.jamcollsurg.2012.09.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The decision to transfuse packed RBCs (PRBC) during initial resuscitation of trauma patients is based on physiologic state, evidence for blood loss, and potential for ongoing hemorrhage. Initial hematocrit (Hct) is not considered an accurate marker of blood loss. This study tests the hypothesis that admission Hct is associated with transfusion requirements after trauma. METHODS From June to December 2008, data from 1,492 consecutive admissions at a Level I trauma center were retrospectively reviewed to determine whether initial Hct was associated with PRBC transfusions. From October 2009 through October 2011, data from 463 consecutive transfused patients were retrospectively reviewed to determine whether Hct correlated with number of PRBC units received. RESULTS Packed RBC transfusion was not correlated with heart rate and was more highly correlated with Hct (r = -0.45) than with systolic blood pressure or base deficit (r = -0.32 or r = -0.26). Hematocrit was a better overall predictor than systolic blood pressure (sensitivity 45% vs 29%, specificity 94% vs 98%, area under receiver operator characteristic curve 0.71 vs 0.64). Lower Hct was associated with hypotension, more advanced shock, higher blood loss, and increased transfusion of PRBC, plasma, platelets, or cryoprecipitate (all, p < 0.01). CONCLUSION Admission Hct is more strongly associated with the PRBC transfusion than either tachycardia, hypotension, or acidosis. Admission Hct is also correlated with 24-hour blood product requirements in those receiving early transfusions. These findings challenge current thinking and suggest that fluid shifts are rapid after trauma and that Hct can be important in initial trauma assessment.
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Affiliation(s)
- Chad M Thorson
- Division of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, FL 33136, USA
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