1
|
Stahel PF, Ziran N. The pathophysiology of pelvic ring injuries: a review. Patient Saf Surg 2024; 18:16. [PMID: 38741186 DOI: 10.1186/s13037-024-00396-x] [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: 02/16/2024] [Accepted: 04/04/2024] [Indexed: 05/16/2024] Open
Abstract
Traumatic pelvic ring injuries continue to represent a major challenge due to the high rates of post-injury mortality of around 30-40% in the peer-reviewed literature. The main root cause of potentially preventable mortality relates to the delayed recognition of the extent of retroperitoneal hemorrhage and post-injury coagulopathy. The understanding of the underlying pathophysiology of pelvic trauma is predicated by classification systems for grading of injury mechanism and risk stratification for developing post-injury coagulopathy with subsequent uncontrolled exsanguinating hemorrhage. This review article elaborates on the current understanding of the pathophysiology of severe pelvic trauma with a focus on the underlying mechanisms of retroperitoneal bleeding and associated adverse outcomes.
Collapse
Affiliation(s)
- Philip F Stahel
- Department of Surgery, East Carolina University, Brody School of Medicine, 27834, Greenville, NC, USA.
- Rocky Vista University, College of Osteopathic Medicine, 80134, Parker, CO, USA.
- Mission Health, HCA Healthcare, North Carolina Division, 28803, Asheville, NC, USA.
| | - Navid Ziran
- St. Joseph's Hospital and Medical Center, 85020, Phoenix, AZ, USA
- North Bay Medical Center, 94534, Fairfield, CA, USA
- Satori Orthopaedics, Inc, 85020, Phoenix, AZ, USA
| |
Collapse
|
2
|
Keltner NM, Cushing MM, Haas T, Spinella PC. Analyzing and modeling massive transfusion strategies and the role of fibrinogen-How much is the patient actually receiving? Transfusion 2024; 64 Suppl 2:S136-S145. [PMID: 38433522 DOI: 10.1111/trf.17774] [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: 12/30/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Hemorrhage is a leading cause of preventable death in trauma, cardiac surgery, liver transplant, and childbirth. While emphasis on protocolization and ratio of blood product transfusion improves ability to treat hemorrhage rapidly, tools to facilitate understanding of the overall content of a specific transfusion strategy are lacking. Medical modeling can provide insights into where deficits in treatment could arise and key areas for clinical study. By using a transfusion model to gain insight into the aggregate content of massive transfusion protocols (MTPs), clinicians can optimize protocols and create opportunities for future studies of precision transfusion medicine in hemorrhage treatment. METHODS The transfusion model describes the individual round and aggregate content provided by four rounds of MTP, illustrating that the total content of blood elements and coagulation factor changes over time, independent of the patient's condition. The configurable model calculates the aggregate hematocrit, platelet concentration, percent volume plasma, total grams and concentration of citrate, percent volume anticoagulant and additive solution, and concentration of clotting factors: fibrinogen, factor XIII, factor VIII, and von Willebrand factor, provided by the MTP strategy. RESULTS Transfusion strategies based on a 1:1:1 or whole blood foundation provide between 13.7 and 17.2 L of blood products over four rounds. Content of strategies varies widely across all measurements based on base strategy and addition of concentrated sources of fibrinogen and other key clotting factors. DISCUSSION Differences observed between modeled transfusion strategies provide key insights into potential opportunities to provide patients with precision transfusion strategy.
Collapse
Affiliation(s)
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine and Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Thorsten Haas
- Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
3
|
Lubkin DT, Mueck KM, Hatton GE, Brill JB, Sandoval M, Cardenas JC, Wade CE, Cotton BA. Does an early, balanced resuscitation strategy reduce the incidence of hypofibrinogenemia in hemorrhagic shock? Trauma Surg Acute Care Open 2024; 9:e001193. [PMID: 38596569 PMCID: PMC11002398 DOI: 10.1136/tsaco-2023-001193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 03/20/2024] [Indexed: 04/11/2024] Open
Abstract
Objectives Some centers have recommended including concentrated fibrinogen replacement in massive transfusion protocols (MTPs). Given our center's policy of aggressive early balanced resuscitation (1:1:1), beginning prehospital, we hypothesized that our rates of hypofibrinogenemia may be lower than those previously reported. Methods In this retrospective cohort study, patients presenting to our trauma center November 2017 to April 2021 were reviewed. Patients were defined as hypofibrinogenemic (HYPOFIB) if admission fibrinogen <150 or rapid thrombelastography angle <60. Univariate and multivariable analyses assessed risk factors for HYPOFIB. Inverse probability of treatment weighting analyses assessed the relationship between cryoprecipitate administration and outcomes. Results Of 29 782 patients, 6618 level 1 activations, and 1948 patients receiving emergency release blood, <1%, 2%, and 7% were HYPOFIB. HYPOFIB patients were younger, had higher head Abbreviated Injury Scale value, and had worse coagulopathy and shock. HYPOFIB had lower survival (48% vs 82%, p<0.001), shorter time to death (median 28 (7, 50) vs 36 (14, 140) hours, p=0.012), and were more likely to die from head injury (72% vs 51%, p<0.001). Risk factors for HYPOFIB included increased age (OR (95% CI) 0.98 (0.96 to 0.99), p=0.03), head injury severity (OR 1.24 (1.06 to 1.46), p=0.009), lower arrival pH (OR 0.01 (0.001 to 0.20), p=0.002), and elevated prehospital red blood cell to platelet ratio (OR 1.20 (1.02 to 1.41), p=0.03). Among HYPOFIB patients, there was no difference in survival for those that received early cryoprecipitate (within 2 hours; 40 vs 47%; p=0.630). On inverse probability of treatment weighted analysis, early cryoprecipitate did not benefit the full cohort (OR 0.52 (0.43 to 0.65), p<0.001), nor the HYPOFIB subgroup (0.28 (0.20 to 0.39), p<0.001). Conclusions Low rates of hypofibrinogenemia were found in our center which treats hemorrhage with early, balanced resuscitation. Previously reported higher rates may be partially due to unbalanced resuscitation and/or delay in resuscitation initiation. Routine empiric inclusion of concentrated fibrinogen replacement in MTPs is not supported by the currently available data. Level of evidence Level III.
Collapse
Affiliation(s)
- David T Lubkin
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Krislynn M Mueck
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Gabrielle E Hatton
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jason B Brill
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mariela Sandoval
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jessica C Cardenas
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Charles E Wade
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Bryan A Cotton
- Surgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| |
Collapse
|
4
|
Starr N, Kornblith L. Prehospital balanced resuscitation may mitigate hypofibrinogenemia in traumatic hemorrhagic shock. Trauma Surg Acute Care Open 2024; 9:e001354. [PMID: 38596567 PMCID: PMC11002369 DOI: 10.1136/tsaco-2023-001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Affiliation(s)
- Nichole Starr
- Surgery, University of California San Francisco, San Francisco, California, USA
- Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Lucy Kornblith
- Surgery, University of California San Francisco, San Francisco, California, USA
- Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| |
Collapse
|
5
|
Van Gent JM, Kaminski CW, Praestholm C, Pivalizza EG, Clements TW, Kao LS, Stanworth S, Brohi K, Cotton BA. Empiric Cryoprecipitate Transfusion in Patients with Severe Hemorrhage: Results from the US Experience in the International CRYOSTAT-2 Trial. J Am Coll Surg 2024; 238:636-643. [PMID: 38146823 DOI: 10.1097/xcs.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
Abstract
BACKGROUND Hypofibrinogenemia has been shown to predict massive transfusion and is associated with higher mortality in severely injured patients. However, the role of empiric fibrinogen replacement in bleeding trauma patients remains controversial. We sought to determine the effect of empiric cryoprecipitate as an adjunct to a balanced transfusion strategy (1:1:1). STUDY DESIGN This study is a subanalysis of patients treated at the single US trauma center in a multicenter randomized controlled trial. Trauma patients (more than 15 years) were eligible if they had evidence of active hemorrhage requiring emergent surgery or interventional radiology, massive transfusion protocol (MTP) activation, and received at least 1 unit of blood. Transfer patients, those with injuries incompatible with life, or those injured more than 3 hours earlier were excluded. Patients were randomized to standard MTP (STANDARD) or MTP plus 3 pools of cryoprecipitate (CRYO). Primary outcomes included all-cause mortality at 28 days. Secondary outcomes were transfusion requirements, intraoperative and postoperative coagulation laboratory values, and quality-of-life measures (Glasgow outcome score-extended). RESULTS Forty-nine patients (23 in the CRYO group and 26 in the STANDARD group) were enrolled between May 2021 and October 2021. Time to randomization was similar between groups (14 vs 24 minutes, p = 0.676). Median time to cryoprecipitate was 41 minutes (interquartile range 37 to 48). There were no differences in demographics, arrival physiology, laboratory values, or injury severity. Intraoperative and ICU thrombelastography values, including functional fibrinogen, were similar between groups. There was no benefit to CRYO with respect to post-emergency department transfusions (intraoperative and ICU through 24 hours), complications, Glasgow outcome score, or mortality. CONCLUSIONS In this study of severely injured, bleeding trauma patients, empiric cryoprecipitate did not improve survival or reduce transfusion requirements. Cryoprecipitate should continue as an "on-demand" addition to a balanced transfusion strategy, guided by laboratory values and should not be given empirically.
Collapse
Affiliation(s)
- Jan-Michael Van Gent
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Carter W Kaminski
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Caroline Praestholm
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Evan G Pivalizza
- Anesthesiology (Pivalizza), McGovern Medical School, Houston, TX
| | - Thomas W Clements
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
| | - Lillian S Kao
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
- The Center for Translational Injury Research, Houston, TX (Kao, Cotton)
| | | | - Karim Brohi
- Department of Haematology, University of Oxford, UK (Brohi)
| | - Bryan A Cotton
- From the Departments of Surgery (Van Gent, Kaminski, Praestholm, Clements, Kao, Cotton)
- The Center for Translational Injury Research, Houston, TX (Kao, Cotton)
| |
Collapse
|
6
|
Sulimai N, Brown J, Lominadze D. The Effect of Reduced Fibrinogen on Cerebrovascular Permeability during Traumatic Brain Injury in Fibrinogen Gene Heterozygous Knockout Mice. Biomolecules 2024; 14:385. [PMID: 38672403 PMCID: PMC11048347 DOI: 10.3390/biom14040385] [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: 02/09/2024] [Revised: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Vascular contribution to cognitive impairment and dementia (VCID) is a term referring to all types of cerebrovascular and cardiovascular disease-related cognitive decline, spanning many neuroinflammatory diseases including traumatic brain injury (TBI). This becomes particularly important during mild-to-moderate TBI (m-mTBI), which is characterized by short-term memory (STM) decline. Enhanced cerebrovascular permeability for proteins is typically observed during m-mTBI. We have previously shown that an increase in the blood content of fibrinogen (Fg) during m-mTBI results in enhanced cerebrovascular permeability. Primarily extravasated via a transcellular pathway, Fg can deposit into the parenchyma and exacerbate inflammatory reactions that can lead to neurodegeneration, resulting in cognitive impairment. In the current study, we investigated the effect of a chronic reduction in Fg concentration in blood on cerebrovascular permeability and the interactions of extravasated Fg with astrocytes and neurons. Cortical contusion injury (CCI) was used to generate m-mTBI in transgenic mice with a deleted Fg γ chain (Fg γ+/-), resulting in a low blood content of Fg, and in control C57BL/6J wild-type (WT) mice. Cerebrovascular permeability was tested in vivo. Interactions of Fg with astrocytes and neurons and the expression of neuronal nuclear factor-кB (NF-кB) were assessed via immunohistochemistry. The results showed that 14 days after CCI, there was less cerebrovascular permeability, lower extravascular deposition of Fg, less activation of astrocytes, less colocalization of Fg with neurons, and lower expression of neuronal pro-inflammatory NF-кB in Fg γ+/- mice compared to that found in WT mice. Combined, our data provide strong evidence that increased Fg extravasation, and its resultant extravascular deposition, triggers astrocyte activation and leads to potential interactions of Fg with neurons, resulting in the overexpression of neuronal NF-кB. These effects suggest that reduced blood levels of Fg can be beneficial in mitigating the STM reduction seen in m-mTBI.
Collapse
Affiliation(s)
- Nurul Sulimai
- Department of Surgery, College of Medicine, University of South Florida Morsani, Tampa, FL 33612, USA; (N.S.); (J.B.)
| | - Jason Brown
- Department of Surgery, College of Medicine, University of South Florida Morsani, Tampa, FL 33612, USA; (N.S.); (J.B.)
| | - David Lominadze
- Department of Surgery, College of Medicine, University of South Florida Morsani, Tampa, FL 33612, USA; (N.S.); (J.B.)
- Department of Molecular Pharmacology and Physiology, College of Medicine, University of South Florida Morsani, Tampa, FL 33612, USA
| |
Collapse
|
7
|
Cralley AL, Moore EE, LaCroix I, Schaid TJ, Thielen O, Hallas W, Hom P, Mitra S, Kelher M, Hansen K, Cohen M, Silliman C, Sauaia A, Fox CJ. RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA: ZONE 1 REPERFUSION-INDUCED COAGULOPATHY. Shock 2024; 61:322-329. [PMID: 38407818 PMCID: PMC10955717 DOI: 10.1097/shk.0000000000002299] [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] [Indexed: 02/27/2024]
Abstract
ABSTRACT Objective: We sought to identify potential drivers behind resuscitative endovascular balloon occlusion of the aorta (REBOA) induced reperfusion coagulopathy using novel proteomic methods. Background: Coagulopathy associated with REBOA is poorly defined. The REBOA Zone 1 provokes hepatic and intestinal ischemia that may alter coagulation factor production and lead to molecular pathway alterations that compromises hemostasis. We hypothesized that REBOA Zone 1 would lead to reperfusion coagulopathy driven by mediators of fibrinolysis, loss of coagulation factors, and potential endothelial dysfunction. Methods: Yorkshire swine were subjected to a polytrauma injury (blast traumatic brain injury, tissue injury, and hemorrhagic shock). Pigs were randomized to observation only (controls, n = 6) or to 30 min of REBOA Zone 1 (n = 6) or REBOA Zone 3 (n = 4) as part of their resuscitation. Thromboelastography was used to detect coagulopathy. ELISA assays and mass spectrometry proteomics were used to measure plasma protein levels related to coagulation and systemic inflammation. Results: After the polytrauma phase, balloon deflation of REBOA Zone 1 was associated with significant hyperfibrinolysis (TEG results: REBOA Zone 1 35.50% versus control 9.5% vs. Zone 3 2.4%, P < 0.05). In the proteomics and ELISA results, REBOA Zone 1 was associated with significant decreases in coagulation factor XI and coagulation factor II, and significant elevations of active tissue plasminogen activator, plasmin-antiplasmin complex complexes, and syndecan-1 (P < 0.05). Conclusion: REBOA Zone 1 alters circulating mediators of clot formation, clot lysis, and increases plasma levels of known markers of endotheliopathy, leading to a reperfusion-induced coagulopathy compared with REBOA Zone 3 and no REBOA.
Collapse
Affiliation(s)
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Aurora, CO USA
- Ernest E Moore Shock Trauma Center at Denver Health Medical Center Surgery, Denver, CO USA
| | - Ian LaCroix
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO USA
| | - TJ Schaid
- Department of Surgery, University of Colorado, Aurora, CO USA
| | - Otto Thielen
- Department of Surgery, University of Colorado, Aurora, CO USA
| | - William Hallas
- Department of Surgery, University of Colorado, Aurora, CO USA
| | - Patrick Hom
- Department of Surgery, University of Colorado, Aurora, CO USA
| | | | | | - Kirk Hansen
- Department of Proteomics and Metabolomics, University of Colorado, Aurora, CO USA
| | - Mitchell Cohen
- Department of Surgery, University of Colorado, Aurora, CO USA
| | - Christopher Silliman
- Vitalant Research Institute, Denver, CO USA
- Department of Pediatrics, University of Colorado, Aurora, CO USA
| | - Angela Sauaia
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado Denver, Aurora, CO, USA
| | - Charles J Fox
- Department of Vascular Surgery, University of Maryland Vascular Surgery Baltimore, MD USA
| |
Collapse
|
8
|
Buzzard L, Schreiber M. Trauma-induced coagulopathy: What you need to know. J Trauma Acute Care Surg 2024; 96:179-185. [PMID: 37828662 DOI: 10.1097/ta.0000000000004170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
ABSTRACT Trauma-induced coagulopathy (TIC) is a global inflammatory state accompanied by coagulation derangements, acidemia, and hypothermia, which occurs after traumatic injury. It occurs in approximately 25% of severely injured patients, and its incidence is directly related to injury severity. The mechanism of TIC is multifaceted; proposed contributing factors include dysregulation of activated protein C, increased tPA, systemic endothelial activation, decreased fibrinogen, clotting factor consumption, and platelet dysfunction. Effects of TIC include systemic inflammation, coagulation derangements, acidemia, and hypothermia. Trauma-induced coagulopathy may be diagnosed by conventional coagulation tests including platelet count, Clauss assay, international normalized ratio, thrombin time, prothrombin time, and activated partial thromboplastin time; viscoelastic hemostatic assays such as thrombelastography and rotational thrombelastography; or a clinical scoring system known as the Trauma Induced Coagulopathy Clinical Score. Preventing TIC begins in the prehospital phase with early hemorrhage control, blood product resuscitation, and tranexamic acid therapy. Early administration of prothrombin complex concentrate is also being studied in the prehospital environment. The mainstays of TIC treatment include hemorrhage control, blood and component transfusions, and correction of abnormalities such as hypocalcemia, acidosis, and hypothermia. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
Affiliation(s)
- Lydia Buzzard
- From the University of Wisconsin School of Medicine and Public Health (L.B.), Madison, Wisconsin; and Department of Surgery (L.B., M.S.), Oregon Health and Science University, Portland, Oregon
| | | |
Collapse
|
9
|
Dorken-Gallastegi A, Bokenkamp M, Argandykov D, Mendoza AE, Hwabejire JO, Saillant N, Fagenholz PJ, Kaafarani HMA, Velmahos GC, Parks JJ. Optimal dose of cryoprecipitate in massive transfusion following trauma. J Trauma Acute Care Surg 2024; 96:137-144. [PMID: 37335138 DOI: 10.1097/ta.0000000000004060] [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] [Indexed: 06/21/2023]
Abstract
BACKGROUND While cryoprecipitate (Cryo) is commonly included in massive transfusion protocols for hemorrhagic shock, the optimal dose of Cryo transfusion remains unknown. We evaluated the optimal red blood cell (RBC) to RBC to Cryo ratio during resuscitation in massively transfused trauma patients. METHODS Adult patients in the American College of Surgeon Trauma Quality Improvement Program (2013-2019) receiving massive transfusion (≥4 U of RBCs, ≥1 U of fresh frozen plasma, and ≥1 U of platelets within 4 hours) were included. A unit of Cryo was defined as a pooled unit of 100 mL. The RBC:Cryo ratio was calculated for blood products transfused within 4 hours of presentation. The association between RBC:Cryo and 24-hour mortality was analyzed with multivariable logistic regression adjusting for the volume of RBC, plasma and platelet transfusions, global and regional injury severity, and other relevant variables. RESULTS The study cohort included 12,916 patients. Among those who received Cryo (n = 5,511 [42.7%]), the median RBC and Cryo transfusion volume within 4 hours was 11 U (interquartile range, 7-19 U) and 2 U (interquartile range, 1-3 U), respectively. Compared with no Cryo administration, only RBC:Cryo ratios ≤8:1 were associated with a significant survival benefit, while lower doses of Cryo (RBC:Cryo >8:1) were not associated with decreased 24-hour mortality. Compared with the maximum dose of Cryo administration (RBC:Cryo, 1:1-2:1), there was no difference in 24-hour mortality up to RBC:Cryo of 7:1 to 8:1, whereas lower doses of Cryo (RBC:Cryo, >8:1) were associated with significantly increased 24-hour mortality. CONCLUSION One pooled unit of Cryo (100 mL) per 7 to 8 U of RBCs could be the optimal dose of Cryo in trauma resuscitation that provides a significant survival benefit while avoiding unnecessary blood product transfusions. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
Collapse
Affiliation(s)
- Ander Dorken-Gallastegi
- From the Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Peng S, Lv K. The role of fibrinogen in traumatic brain injury: from molecular pathological mechanisms to clinical management. Eur J Trauma Emerg Surg 2023; 49:1665-1672. [PMID: 35972516 DOI: 10.1007/s00068-022-02084-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/08/2022] [Indexed: 11/28/2022]
Abstract
Fibrinogen is the substrate of plasma coagulation. It plays an important role in the formation of reticular network, which is crucial to the strength and stability of blood clots. In addition to directly participating in coagulation, fibrinogen also participates in the destruction of blood-brain barrier and neuroinflammation. This article reviews the pathophysiological changes of fibrinogen after traumatic brain injury. Considerable efforts have been made to understand the mechanisms by which fibrinogen damages the central nervous system. Combined with the latest research hotspots, potentially promising treatment strategies at the molecular level were discussed. We believe that understanding the role of fibrinogen-mediated damage in nerve and blood-brain barrier function will enable timely intervention in patients with nerve damage, and guide the development of novel targeted therapeutics.
Collapse
Affiliation(s)
- Shixin Peng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China
| | - Ke Lv
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, China.
| |
Collapse
|
11
|
Schmitt J, Gurney J, Aries P, Danguy Des Deserts M. Advances in trauma care to save lives from traumatic injury: A narrative review. J Trauma Acute Care Surg 2023; 95:285-292. [PMID: 36941236 DOI: 10.1097/ta.0000000000003960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
ABSTRACT Recent advances on trauma management from the prehospital setting to in hospital care led to a better surviving severe trauma rate. Mortality from exsanguination remains the first preventable mortality. Damage-control resuscitation and surgery are evolving and thus some promising concepts are developing. Transfusion toolkit is brought on the prehospital scene while temporary bridge to hemostasis may be helpful. Panel transfusion products allow an individualized ratio assumed by fresh frozen or lyophilized plasma, fresh or cold-stored whole blood, fibrinogen, four-factor prothrombin complex concentrates. Growing interest is raising in whole blood transfusion, resuscitative endovascular balloon occlusion of the aorta use, hybrid emergency room, viscoelastic hemostatic assays to improve patient outcomes. Microcirculation, traumatic endotheliopathy, organ failures and secondary immunosuppression are point out since late deaths are increasing and may deserve specific treatment.As each trauma patient follows his own course over the following days after trauma, trauma management may be seen through successive, temporal, and individualized aims.
Collapse
Affiliation(s)
- Johan Schmitt
- From the Intensive Care Unit, Military Teaching Hospital Clermont Tonnerre (S.J., A.P., D.D.D.M.), Brest, France; US Army Institute of Surgical Research (G.J.), San Antonio, Texas; and Joint Trauma System, DoD Center of Excellence for Trauma (G.J.), San Antonio, Texas
| | | | | | | |
Collapse
|
12
|
Richards J, Fedeles BT, Chow JH, Scalea T, Kozar R. Raising the bar on fibrinogen: a retrospective assessment of critical hypofibrinogenemia in severely injured trauma patients. Trauma Surg Acute Care Open 2023; 8:e000937. [PMID: 36726403 PMCID: PMC9884899 DOI: 10.1136/tsaco-2022-000937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/04/2022] [Indexed: 01/26/2023] Open
Abstract
Objectives Fibrinogen depletion may occur at higher levels than historically referenced. We evaluated hypofibrinogenemia and associated mortality and multiple organ failure (MOF) after severe injury. Methods Retrospective investigation including 417 adult patients with Injury Severity Score (ISS) >15. Demographics and injury characteristics were collected. Fibrinogen within 30 minutes of admission was described: <150 mg/dL, 150 mg/dL to 200 mg/dL and >200 mg/dL. Primary outcome: 28-day mortality. Secondary outcomes: 28-day MOF and blood product transfusion. Multivariable logistic regression model evaluated association of fibrinogen categories on risk of death, after controlling for confounding variables. Results presented as OR and 95% CIs. Results Fibrinogen <150 mg/dL: 4.8%, 150 mg/dL to 200 mg/dL: 18.2%, >200 mg/dL: 77.0%. 28-day mortality: 15.6%. Patients with <150 mg/dL fibrinogen had over fourfold increased 28-day mortality risk (OR: 4.9, 95% CI 1.53 to 15.7) after adjusting for age, ISS and admission Glasgow Coma Scale. Patients with lower fibrinogen were more likely to develop MOF (p=0.04) and receive larger red blood cell transfusion volumes at 3 hours and 24 hours (p<0.01). Conclusions Fibrinogen <150 mg/dL is significantly associated with increased 28-day mortality. Patients with fibrinogen <150 mg/dL were more likely to develop MOF and required increased administration of blood products. The optimal threshold for critically low fibrinogen, the association with MOF and subsequent fibrinogen replacement requires further investigation. Level of evidence Level III.
Collapse
Affiliation(s)
- Justin Richards
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA,R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Benjamin T Fedeles
- Department of Anesthesiology and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rosemary Kozar
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA,Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
13
|
Neidert LE, Morgan CG, Hathaway EN, Hemond PJ, Tiller MM, Cardin S, Glaser JJ. Effects of hemodilution on coagulation function during prolonged hypotensive resuscitation in a porcine model of severe hemorrhagic shock. Trauma Surg Acute Care Open 2023; 8:e001052. [PMID: 37213865 PMCID: PMC10193089 DOI: 10.1136/tsaco-2022-001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/27/2023] [Indexed: 05/23/2023] Open
Abstract
Background Although hemorrhage remains the leading cause of survivable death in casualties, modern conflicts are becoming more austere limiting available resources to include resuscitation products. With limited resources also comes prolonged evacuation time, leaving suboptimal prehospital field care conditions. When blood products are limited or unavailable, crystalloid becomes the resuscitation fluid of choice. However, there is concern of continuous crystalloid infusion during a prolonged period to achieve hemodynamic stability for a patient. This study evaluates the effect of hemodilution from a 6-hour prehospital hypotensive phase on coagulation in a porcine model of severe hemorrhagic shock. Methods Adult male swine (n=5/group) were randomized into three experimental groups. Non-shock (NS)/normotensive did not undergo injury and were controls. NS/permissive hypotensive (PH) was bled to the PH target of systolic blood pressure (SBP) 85±5 mm Hg for 6 hours of prolonged field care (PFC) with SBP maintained via crystalloid, then recovered. Experimental group underwent controlled hemorrhage to mean arterial pressure 30 mm Hg until decompensation (Decomp/PH), followed by PH resuscitation with crystalloid for 6 hours. Hemorrhaged animals were then resuscitated with whole blood and recovered. Blood samples were collected at certain time points for analysis of complete blood counts, coagulation function, and inflammation. Results Throughout the 6-hour PFC, hematocrit, hemoglobin, and platelets showed significant decreases over time in the Decomp/PH group, indicating hemodilution, compared with the other groups. However, this was corrected with whole blood resuscitation. Despite the appearance of hemodilution, coagulation and perfusion parameters were not severely compromised. Conclusions Although significant hemodilution occurred, there was minimal impact on coagulation and endothelial function. This suggests that it is possible to maintain the SBP target to preserve perfusion of vital organs at a hemodilution threshold in resource-constrained environments. Future studies should address therapeutics that can mitigate potential hemodilutional effects such as lack of fibrinogen or platelets. Level of evidence Not applicable-Basic Animal Research.
Collapse
Affiliation(s)
- Leslie E Neidert
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Clifford G Morgan
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Emily N Hathaway
- Division of Trauma, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas, USA
| | - Peter J Hemond
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Michael M Tiller
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
- Division of Trauma, Brooke Army Medical Center, JBSA-Fort Sam Houston, Texas, USA
| | - Sylvain Cardin
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
| | - Jacob J Glaser
- Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio, JBSA-Fort Sam Houston, Texas, USA
- Trauma and Acute Care Surgery, Providence Regional Medical Center Everett, Everett, Washington, USA
| |
Collapse
|
14
|
Russell RT, Esparaz JR, Beckwith MA, Abraham PJ, Bembea MM, Borgman MA, Burd RS, Gaines BA, Jafri M, Josephson CD, Leeper C, Leonard JC, Muszynski JA, Nicol KK, Nishijima DK, Stricker PA, Vogel AM, Wong TE, Spinella PC. Pediatric traumatic hemorrhagic shock consensus conference recommendations. J Trauma Acute Care Surg 2023; 94:S2-S10. [PMID: 36245074 PMCID: PMC9805499 DOI: 10.1097/ta.0000000000003805] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
ABSTRACT Hemorrhagic shock in pediatric trauma patients remains a challenging yet preventable cause of death. There is little high-quality evidence available to guide specific aspects of hemorrhage control and specific resuscitation practices in this population. We sought to generate clinical recommendations, expert consensus, and good practice statements to aid providers in care for these difficult patients.The Pediatric Traumatic Hemorrhagic Shock Consensus Conference process included systematic reviews related to six subtopics and one consensus meeting. A panel of 16 consensus multidisciplinary committee members evaluated the literature related to 6 specific topics: (1) blood products and fluid resuscitation for hemostatic resuscitation, (2) utilization of prehospital blood products, (3) use of hemostatic adjuncts, (4) tourniquet use, (5) prehospital airway and blood pressure management, and (6) conventional coagulation tests or thromboelastography-guided resuscitation. A total of 21 recommendations are detailed in this article: 2 clinical recommendations, 14 expert consensus statements, and 5 good practice statements. The statement, the panel's voting outcome, and the rationale for each statement intend to give pediatric trauma providers the latest evidence and guidance to care for pediatric trauma patients experiencing hemorrhagic shock. With a broad multidisciplinary representation, the Pediatric Traumatic Hemorrhagic Shock Consensus Conference systematically evaluated the literature and developed clinical recommendations, expert consensus, and good practice statements concerning topics in traumatically injured pediatric patients with hemorrhagic shock.
Collapse
Affiliation(s)
- Robert T. Russell
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL
| | - Joseph R. Esparaz
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, AL
| | - Michael A. Beckwith
- Department of Surgery, Division of Pediatric Surgery, University of Michigan, Ann Arbor, MIS
| | - Peter J. Abraham
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Melania M. Bembea
- Division of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew A. Borgman
- Department of Pediatrics, Brooke Army Medical Center, Uniformed Services University
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Barbara A. Gaines
- Department of Surgery, University of Pittsburgh School of Medicine, UPMC Children’s Hospital, Pittsburgh, PA
| | - Mubeen Jafri
- Division of Pediatric Surgery, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR
| | - Cassandra D. Josephson
- Departments of Pathology and Laboratory Medicine and Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Christine Leeper
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Julie C. Leonard
- Department of Pediatrics, Division of Emergency Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Kathleen K. Nicol
- Department of Pathology and Laboratory Medicine, The Ohio State University College of Medicine Nationwide Children’s Hospital, Columbus, OH
| | - Daniel K. Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Paul A. Stricker
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Adam M. Vogel
- Divisions of Pediatric Surgery and Critical Care, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Trisha E. Wong
- Division of Pediatric Hematology and Oncology and Department of Pathology, Oregon Health & Science University, Portland, OR
| | - Philip C. Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh Medical Center. Pittsburgh, PA
| |
Collapse
|
15
|
Transfusion management in the trauma patient. Curr Opin Crit Care 2022; 28:725-731. [PMID: 36226706 DOI: 10.1097/mcc.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Transfusion of blood products is lifesaving in the trauma ICU. Intensivists must be familiar with contemporary literature to develop the optimal transfusion strategy for each patient. RECENT FINDINGS A balanced ratio of red-blood cells to plasma and platelets is associated with improved mortality and has therefore become the standard of care for resuscitation. There is a dose-dependent relationship between units of product transfused and infections. Liquid and freeze-dried plasma are alternatives to fresh frozen plasma that can be administered immediately and may improve coagulation parameters more rapidly, though higher quality research is needed. Trauma induced coagulopathy can occur despite a balanced transfusion, and administration of prothrombin complex concentrate and cryoprecipitate may have a role in preventing this. In addition to balanced ratios, viscoelastic guidance is being increasingly utilized to individualize component transfusion. Alternatively, whole blood can be used, which has become the standard in military practice and is gaining popularity at civilian centers. SUMMARY Hemorrhagic shock is the leading cause of death in trauma. Improved resuscitation strategy has been one of the most important contemporary advancements in trauma care and continues to be a key area of clinical research.
Collapse
|
16
|
DeBot M, Eitel AP, Moore EE, Sauaia A, Lutz P, Schaid TR, Hadley JB, Kissau DJ, Cohen MJ, Kelher MR, Silliman CC. BLOOD TYPE O IS A RISK FACTOR FOR HYPERFIBRINOLYSIS AND MASSIVE TRANSFUSION AFTER SEVERE INJURY. Shock 2022; 58:492-497. [PMID: 36548640 PMCID: PMC9793952 DOI: 10.1097/shk.0000000000002013] [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] [Indexed: 12/24/2022]
Abstract
ABSTRACT Background: Blood type O is the most common blood type and has lower von Willebrand factor (vWF) levels (25%-35% lower than non-O blood types). von Willebrand factor is important for initiating platelet attachment and binding factor VIII. We hypothesized that patients with type O blood are at an increased risk of trauma-induced coagulopathy and bleeding post injury. Study Design: Adult trauma activations with known blood type at a level I trauma center with field systolic blood pressure < 90 mm Hg were studied retrospectively. The relationships of blood group O versus non-O to coagulation assays, massive transfusion (MT), ventilator-free days, and mortality were adjusted for confounders. Hyperfibrinolysis (HF) was defined as thromboelastogram of percent lysis in 30 min > 3%, and fibrinolysis shutdown was defined as percent lysis in 30 min < 0.9%. von Willebrand factor activity was quantified on 212 injured patients using a STAGO apparatus. Results: Overall, 268 patients met criteria. Type O patients were more likely to develop HF than non-type O blood patients (43% vs. 29%, P = 0.06) and had significantly lower vWF activity (222% vs. 249%, P = 0.01). After adjustment for New Injury Severity Score and blunt mechanism, type O had higher odds of HF (odds ratio, 1.94, 95% confidence interval, 1.09-3.47) and increased odds of MT (odds ratio, 3.02; 95% confidence interval, 1.22-7.49). Other outcomes were not significantly affected. Conclusion: Type O patients with hypotension had increased HF and MT post injury, and these were associated with lower vWF activity. These findings have implications for the monitoring of HF in patients receiving type O whole-blood transfusions post injury.
Collapse
Affiliation(s)
- Margot DeBot
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Andrew P Eitel
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | | | | | - Patrick Lutz
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Terry R Schaid
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Jamie B Hadley
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Daniel J Kissau
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Mitchell J Cohen
- Department of Surgery/Trauma Research Center, School of Medicine, University of Colorado Denver, Aurora, Colorado
| | | | | |
Collapse
|
17
|
Elgar G, Smiley A, Latifi R. Major Risk Factors for Mortality in Elderly and Non-Elderly Adult Patients Emergently Admitted for Blunt Chest Wall Trauma: Hospital Length of Stay as an Independent Predictor. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148729. [PMID: 35886581 PMCID: PMC9318478 DOI: 10.3390/ijerph19148729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 02/05/2023]
Abstract
Background: Blunt thoracic trauma is responsible for 35% of trauma-related deaths in the United States and significantly contributes to morbidity and healthcare-related financial strain. The goal of this study was to evaluate factors influencing mortality in patients emergently admitted with the primary diagnosis of blunt chest wall trauma. Methods: Adults emergently admitted for blunt chest trauma were assessed using the National Inpatient Sample Database, 2004–2014. Data regarding demographics, comorbidities, and outcomes were collected. Relationships were determined using univariable and multivariable logistic regression models. Results: In total, 1120 adult and 1038 elderly patients emergently admitted with blunt chest trauma were assessed; 46.3% were female, and 53.6% were male. The average ages of adult and elderly patients were 46.6 and 78.9 years, respectively. Elderly and adult patients both displayed mortality rates of 1%. The regression model showed HLOS and several comorbidities as the main risk factors of mortality Every additional day of hospitalization increased the odds of mortality by 9% (OR = 1.09, 95% CI = 1.01–1.18, p = 0.033). Mortality and liver disease were significantly associated (OR = 8.36, 95% CI = 2.23–31.37, p = 0.002). Respiratory disease and mortality rates demonstrated robust correlations (OR = 7.46, 95% CI = 1.63–34.11, p = 0.010). Trauma, burns, and poisons were associated with increased mortality (OR = 3.72, 95% CI = 1.18–11.71, p = 0.025). The presence of platelet/white blood cell disease correlated to higher mortality. (OR = 4.42, 95% CI = 1.09–17.91, p = 0.038).
Collapse
Affiliation(s)
- Guy Elgar
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Correspondence: (G.E.); (A.S.)
| | - Abbas Smiley
- Westchester Medical Center, School of Medicine, New York Medical College, Valhalla, NY 10595, USA
- Correspondence: (G.E.); (A.S.)
| | - Rifat Latifi
- College of Medicine, University of Arizona, Tucson, AZ 85724, USA;
- Ministry of Health, 10000 Pristina, Kosovo
| |
Collapse
|