1
|
Tran A, Lamb T, Taljaard M, Fernando SM, Inaba K, Moore EE, Lampron J, Demetriades D, Haut ER, Vaillancourt C. Current practices and challenges in assessing traumatic hemorrhage: An international survey of trauma care providers. J Trauma Acute Care Surg 2021; 90:e95-e100. [PMID: 33891575 DOI: 10.1097/ta.0000000000003081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Alexandre Tran
- From the Department of Surgery (A.T., T.L., J.L.), The Ottawa Hospital, School of Epidemiology and Public Health (A.T., T.L., M.T.), and Division of Critical Care, Department of Medicine (A.T., S.M.F.), University of Ottawa; Clinical Epidemiology Program (M.T., C.V.), Ottawa Hospital Research Institute; Department of Emergency Medicine (S.M.F., C.V.), University of Ottawa, Ottawa, ON, Canada; Department of Surgery (K.I., D.D.), University of Southern California, Los Angeles, California; Department of Surgery (E.E.M.), University of Denver, Denver, Colorado; Division of Acute Care Surgery, Department of Surgery (E.R.H.), and Department of Anesthesiology and Critical Care, Department of Emergency Medicine (E.R.H.), The Johns Hopkins University School of Medicine; Department of Health Policy and Management (E.R.H.), The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Vishwanathan K, Chhajwani S, Gupta A, Vaishya R. Evaluation and management of haemorrhagic shock in polytrauma: Clinical practice guidelines. J Clin Orthop Trauma 2020; 13:106-115. [PMID: 33680808 PMCID: PMC7919934 DOI: 10.1016/j.jcot.2020.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022] Open
Abstract
Haemorrhagic shock is the most common preventable cause of early mortality in polytrauma patients. Road traffic injuries are the most common cause for polytrauma and most commonly include orthopaedic injuries. Hence, orthopaedic trainees and junior orthopaedic surgeons need to be well aware of evaluation and management of haemorrhagic shock in the multiple injured patient. The present narrative review discusses evaluation and current principles in management of haemorrhagic shock in a polytrauma patient. A classification system for haemorrhagic shock based on ATLS guidelines has been described along with novel use of colour coding to facilitate better and effective use of the classification. A treatment algorithm has also been presented for quick reference. The emphasis is to avoid overloading with crystalloid fluids, replacing with blood and blood products (Balanced resuscitation), permissive hypotension, prevent and acutely treat lethal conditions such as hypothermia, acidosis and coagulopathy. The management of haemorrhagic shock in polytrauma patient is quite challenging and require a detailed knowledge of its management. An arbitrary and haphazard management of these patients may lead to severe complications. We have mentioned the broad principles of management of hypovolemic shock in a polytrauma patient.
Collapse
Affiliation(s)
- Karthik Vishwanathan
- Department of Orthopaedics, Parul Institute of Medical Sciences and Research, Parul University, Vadodara, India
- Corresponding author. Department of Orthopaedics, Parul Institute of Medical Sciences and Research, Faculty of Medicine, Parul University, P.O Limda, Waghodia, Vadodara, 391760, India.
| | - Sunil Chhajwani
- Department of Anaesthesia and Critical Care, Pramukhswami Medical College, Karamsad, India
| | - Amit Gupta
- Division of Trauma Surgery & Critical Care, J.P.N. Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, India
| | - Raju Vaishya
- Department of Orthopaedics & Joint Replacement, Indraprastha Apollo Hospitals, New Delhi, India
| |
Collapse
|
3
|
Tran A, Taljaard M, Abdulaziz KE, Matar M, Lampron J, Steyerberg EW, Vaillancourt C. Early identification of the need for major intervention in patients with traumatic hemorrhage: development and internal validation of a simple bleeding score. Can J Surg 2020. [PMID: 33009903 DOI: 10.1503/cjs.010619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation. METHODS We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance. RESULTS We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89). CONCLUSION A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.
Collapse
Affiliation(s)
- Alexandre Tran
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Monica Taljaard
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Kasim E Abdulaziz
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Maher Matar
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Jacinthe Lampron
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Ewout W Steyerberg
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| | - Christian Vaillancourt
- From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt)
| |
Collapse
|
4
|
Mechanism, frequency, transfusion and outcome of severe trauma in coagulopathic paediatric patients. Eur J Trauma Emerg Surg 2020; 48:153-161. [PMID: 32448940 PMCID: PMC7245642 DOI: 10.1007/s00068-020-01398-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 05/16/2020] [Indexed: 01/22/2023]
Abstract
Purpose Acute traumatic coagulopathy can result in uncontrolled haemorrhage responsible for the majority of early deaths after adult trauma. Data on the frequency, transfusion practice and outcome of severe trauma haemorrhage in paediatric patients are inconsistent. Methods Datasets from paediatric trauma patients were retrieved from the registry of the German trauma society (TR-DGU®) between 2009 and 2016. Coagulopathy was defined by a Quick’s value < 70% (INR (international normalized ratio) > 1.4) and/or thrombocytes ≤ 100 k upon emergency room admission. Children were grouped according to age in 4 different groups (A: 1–5, B: 6–10, C: 11–15 and D: 16–17 years). Prevalence of coagulopathy was assessed. Demographics, injury severity, haemostatic management including transfusions and mortality were described. Results 5351 primary admitted children ≤ 17 years with an abbreviated injury scale (AIS) ≥ 3 and complete datasets were included. The prevalence of coagulopathy was 13.7% (733/5351). The majority of the children sustained blunt trauma (more than 90% independent of age group) and a combination of traumatic brain injury (TBI) and any other trauma in more than 60% (A, C, D) and in 53.8% in group B. Coagulopathy occurred the most among the youngest (A: 18.2%), followed by all other age groups with approximately 13%. Overall mortality was the highest in the youngest (A: 40.9%) and among the youngest patients with traumatic brain injury (A: 71.4% and B: 47.1%). Transfusion of packed red blood cells (pRBCs) and fresh frozen plasma (FFPs) occurred almost in a 2:1 ratio (or less) across all age subgroups. Conclusion Traumatic haemorrhage in association with coagulopathy and severe shock is a major challenge in paediatric trauma across all age groups. Electronic supplementary material The online version of this article (10.1007/s00068-020-01398-x) contains supplementary material, which is available to authorized users.
Collapse
|
5
|
Parks J, Vasileiou G, Parreco J, Pust GD, Rattan R, Zakrison T, Namias N, Yeh DD. Validating the ATLS Shock Classification for Predicting Death, Transfusion, or Urgent Intervention. J Surg Res 2019; 245:163-167. [PMID: 31419641 DOI: 10.1016/j.jss.2019.07.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/19/2019] [Accepted: 07/16/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Advanced Trauma Life Support (ATLS) shock classification has been accepted as the conceptual framework for clinicians caring for trauma patients. We sought to validate its ability to predict mortality, blood transfusion, and urgent intervention. MATERIALS AND METHODS We performed a retrospective review of trauma patients using the 2014 National Trauma Data Bank. Using initial vital signs data, patients were categorized into shock class based on the ATLS program. Rates for urgent blood transfusion, urgent operative intervention, and mortality were compared between classes. RESULTS 630,635 subjects were included for analysis. Classes 1, 2, 3, and 4 included 312,404, 17,133, 31, and 43 patients, respectively. 300,754 patients did not meet criteria for any ATLS shock class. Of the patients in class 1 shock, 2653 died (0.9%), 3123 (1.0%) were transfused blood products, and 7115 (2.3%) underwent an urgent procedure. In class 2, 219 (1.3%) died, 387 (2.3%) were transfused, and 1575 (9.2%) underwent intervention. In class 3, 7 (22.6%) died, 10 (32.3%) were transfused, and 13 (41.9%) underwent intervention. In class 4, 15 (34.9%) died, 19 (44.2%) were transfused, and 23 (53.5%) underwent intervention. For uncategorized patients, 21,356 (7.1%) died, 15,168 (5.0%) were transfused, and 23,844 (7.9%) underwent intervention. CONCLUSIONS Almost half of trauma patients do not meet criteria for any ATLS shock class. Uncategorized patients had a higher mortality (7.1%) than patients in classes 1 and 2 (0.9% and 1.3%, respectively). Classes 3 and 4 only accounted for 0.005% and 0.007%, respectively, of patients. The ATLS classification system does not help identify many patients in severe shock.
Collapse
Affiliation(s)
- Jonathan Parks
- Ryder Trauma Center, University of Miami, Miami, Florida.
| | | | - Joshua Parreco
- Ryder Trauma Center, University of Miami, Miami, Florida
| | - Gerd D Pust
- Ryder Trauma Center, University of Miami, Miami, Florida
| | - Rishi Rattan
- Ryder Trauma Center, University of Miami, Miami, Florida
| | - Tanya Zakrison
- The University of Chicago Medicine, Section for Trauma and Acute Care Surgery, Chicago, Illinois
| | | | - D Dante Yeh
- Ryder Trauma Center, University of Miami, Miami, Florida
| |
Collapse
|
6
|
Arterial waveform morphomics during hemorrhagic shock. Eur J Trauma Emerg Surg 2019; 47:325-332. [DOI: 10.1007/s00068-019-01140-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/17/2019] [Indexed: 11/26/2022]
|
7
|
Foster JC, Sappenfield JW, Smith RS, Kiley SP. Initiation and Termination of Massive Transfusion Protocols: Current Strategies and Future Prospects. Anesth Analg 2017; 125:2045-2055. [PMID: 28857793 DOI: 10.1213/ane.0000000000002436] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The advent of massive transfusion protocols (MTP) has had a significant positive impact on hemorrhaging trauma patient morbidity and mortality. Nevertheless, societal MTP guidelines and individual MTPs at academic institutions continue to circulate opposing recommendations on topics critical to MTPs. This narrative review discusses up-to-date information on 2 such topics, the initiation and termination of an MTP. The discussion for each begins with a review of the recommendations and supporting literature presented by MTP guidelines from 3 prominent societies, the American Society of Anesthesiologists, the American College of Surgeons, and the task force for Advanced Bleeding Care in Trauma. This is followed by an in-depth analysis of the main components within those recommendations. Societal recommendations on MTP initiation in hemorrhaging trauma patients emphasize the use of retrospectively validated massive transfusion (MT) prediction score, specifically, the Assessment of Blood Consumption and Trauma-Associated Severe Hemorrhage scores. Validation studies have shown that both scoring systems perform similarly. Both scores reliably identify patients that will not require an MT, while simultaneously overpredicting MT requirements. However, each scoring system has its unique advantages and disadvantages, and this review discusses how specific aspects of each scoring system can affect widespread applicability and statistical performance. In addition, we discuss the often overlooked topic of initiating MT in nontrauma patients and the specific tools physicians have to guide the MT initiation decision in this unique setting. Despite the serious complications that can arise with transfusion of large volumes of blood products, there is considerably less research pertinent to the topic of MTP termination. Societal recommendations on MTP termination emphasize applying clinical reasoning to identify patients who have bleeding source control and are adequately resuscitated. This review, however, focuses primarily on the recommendations presented by the Advanced Bleeding Care in Trauma's MTP guidelines that call for prompt termination of the algorithm-guided model of resuscitation and rapidly transitioning into a resuscitation model guided by laboratory test results. We also discuss the evidence in support of laboratory result-guided resuscitation and how recent literature on viscoelastic hemostatic assays, although limited, highlights the potential to achieve additional benefits from this method of resuscitation.
Collapse
Affiliation(s)
- John C Foster
- From the University of Florida College of Medicine, Gainesville, Florida
| | - Joshua W Sappenfield
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Robert S Smith
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
| | - Sean P Kiley
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| |
Collapse
|
8
|
Tran A, Matar M, Lampron J, Steyerberg E, Vaillancourt C, Taljaard M. Outcome variation among Canadian trauma centres: toward a clinical prediction rule for standardizing approaches to clinical assessment of hemorrhage. Can J Surg 2017; 60:E3. [PMID: 28930038 DOI: 10.1503/cjs.1760051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
9
|
Ioannides D, Davies M, Kluzek S. Confusion and abdominal symptoms following a rugby tackle. BMJ Case Rep 2017; 2017:bcr-2017-222160. [PMID: 28942415 DOI: 10.1136/bcr-2017-222160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 19-year-old man was sent to the emergency department following a pitch-side assessment for suspected concussion, unexplained upper abdominal tenderness and vomiting, following a high-impact tackle during a rugby match. A Focussed Assessment with Sonography for Trauma (FAST) scan performed in the emergency department suggested intra-abdominal free fluid, and subsequent head and abdominal CT imaging showed no intracranial lesion but confirmed a significant haemoperitoneum due to large splenic tear and bleeding. An emergency splenectomy was performed, which confirmed the rupture of an enlarged spleen with blood loss of almost 2 L into the peritoneal cavity. The patient made a full recovery following surgery. A subsequent histological examination revealed granulomatous inflammation characteristic of infectious mononucleosis. This unique case illustrates that physically fit patients with early hypovolaemic shock can present with symptoms mimicking concussion.
Collapse
Affiliation(s)
- Demetris Ioannides
- Medical Sciences Division, University of Oxford, Oxford, Oxfordshire, UK
| | - Madeleine Davies
- Medical Sciences Division, University of Oxford, Oxford, Oxfordshire, UK
| | - Stefan Kluzek
- The Botnar Research Centre (NDORMS), Oxford University Hospitals, Oxford, UK
| |
Collapse
|
10
|
Tran A, Matar M, Steyerberg EW, Lampron J, Taljaard M, Vaillancourt C. Early identification of patients requiring massive transfusion, embolization, or hemostatic surgery for traumatic hemorrhage: a systematic review protocol. Syst Rev 2017; 6:80. [PMID: 28407781 PMCID: PMC5390372 DOI: 10.1186/s13643-017-0480-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemorrhage is a major cause of early mortality following a traumatic injury. The progression and consequences of significant blood loss occur quickly as death from hemorrhagic shock or exsanguination often occurs within the first few hours. The mainstay of treatment therefore involves early identification of patients at risk for hemorrhagic shock in order to provide blood products and control of the bleeding source if necessary. The intended scope of this review is to identify and assess combinations of predictors informing therapeutic decision-making for clinicians during the initial trauma assessment. The primary objective of this systematic review is to identify and critically assess any existing multivariable models predicting significant traumatic hemorrhage that requires intervention, defined as a composite outcome comprising massive transfusion, surgery for hemostasis, or angiography with embolization for the purpose of external validation or updating in other study populations. If no suitable existing multivariable models are identified, the secondary objective is to identify candidate predictors to inform the development of a new prediction rule. METHODS We will search the EMBASE and MEDLINE databases for all randomized controlled trials and prospective and retrospective cohort studies developing or validating predictors of intervention for traumatic hemorrhage in adult patients 16 years of age or older. Eligible predictors must be available to the clinician during the first hour of trauma resuscitation and may be clinical, lab-based, or imaging-based. Outcomes of interest include the need for surgical intervention, angiographic embolization, or massive transfusion within the first 24 h. Data extraction will be performed independently by two reviewers. Items for extraction will be based on the CHARMS checklist. We will evaluate any existing models for relevance, quality, and the potential for external validation and updating in other populations. Relevance will be described in terms of appropriateness of outcomes and predictors. Quality criteria will include variable selection strategies, adequacy of sample size, handling of missing data, validation techniques, and measures of model performance. DISCUSSION This systematic review will describe the availability of multivariable prediction models and summarize evidence regarding predictors that can be used to identify the need for intervention in patients with traumatic hemorrhage. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017054589.
Collapse
Affiliation(s)
- Alexandre Tran
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario Canada
- Division of General Surgery, The Ottawa Hospital, The Ottawa Hospital Civic Campus, Loeb Research Building, Main Floor, 725 Parkdale Avenue, Office WM150E, Ottawa, Ontario K1Y 4E9 Canada
| | - Maher Matar
- Division of General Surgery, The Ottawa Hospital, The Ottawa Hospital Civic Campus, Loeb Research Building, Main Floor, 725 Parkdale Avenue, Office WM150E, Ottawa, Ontario K1Y 4E9 Canada
| | - Ewout W. Steyerberg
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacinthe Lampron
- Division of General Surgery, The Ottawa Hospital, The Ottawa Hospital Civic Campus, Loeb Research Building, Main Floor, 725 Parkdale Avenue, Office WM150E, Ottawa, Ontario K1Y 4E9 Canada
| | - Monica Taljaard
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Christian Vaillancourt
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| |
Collapse
|
11
|
Mclennan JV, Mackway-Jones KC, Horne ST, Body R. Predictors of massive blood transfusion: a Delphi Study to examine the views of experts. J ROY ARMY MED CORPS 2017; 163:259-265. [PMID: 28320917 DOI: 10.1136/jramc-2016-000702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/30/2016] [Accepted: 10/31/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Trauma patients requiring massive blood transfusion (MBT) have high morbidity and mortality: early and aggressive use of blood products during immediate resuscitation may improve survival. There is currently a lack of evidence to guide initial identification of these patients which is especially important in areas where plasma may need to be thawed. In the absence of this evidence, this study aimed to robustly evaluate expert opinion by using a Delphi process to identify predictors of massive transfusion. This process can be used to ensure that decision rules include variables that have clinical validity, which may improve translation of rules into clinical practice. METHODS An international panel of 35 experts was identified through expert advice against specific criteria. Military and civilian experts from the fields of emergency medicine, critical care, anaesthesia, prehospital care, haematology and general/trauma surgery were included. The Delphi Study was carried out over three rounds. Consensus level was predefined at 80%. RESULTS 195 statements were generated by the panel of which 97 (49.7%) achieved consensus at the 80% level by the end of round 3. Strikingly no clinical observations reached consensus individually. Metabolic acidosis of a base excess of -5.0 or worse, lactate >5 mmol/L and a low haematocrit on arrival were all considered predictive. Some patterns of injury, but few mechanisms of injury, were considered highly predictive of the need of MBT. CONCLUSIONS This Delphi process has produced a list of parameters that expert clinicians felt were predictive for MBT. This list can be used to inform the generation of decision rules. It is of note that many factors used in current decision rules were not valued by clinical experts-this may be a cause for poor uptake of those rules.
Collapse
Affiliation(s)
- Jacqueline V Mclennan
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Academia & Research), Medical Directorate, ICT Centre, Birmingham, UK.,Royal Stoke Hospital, University Hospital North Midlands NHS Trust, Staffordshire, UK
| | - K C Mackway-Jones
- Manchester University, Manchester, UK.,Emergency Department, Manchester Royal Infirmary, Manchester, UK
| | - S T Horne
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Academia & Research), Medical Directorate, ICT Centre, Birmingham, UK.,Emergency Department, Derriford Hospital, Plymouth, UK
| | - R Body
- Manchester University, Manchester, UK.,Emergency Department, Manchester Royal Infirmary, Manchester, UK
| |
Collapse
|
12
|
Loggers SAI, Koedam TWA, Giannakopoulos GF, Vandewalle E, Erwteman M, Zuidema WP. Definition of hemodynamic stability in blunt trauma patients: a systematic review and assessment amongst Dutch trauma team members. Eur J Trauma Emerg Surg 2016; 43:823-833. [PMID: 27900417 PMCID: PMC5707227 DOI: 10.1007/s00068-016-0744-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/21/2016] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Trauma is a great contributor to mortality worldwide. One of the challenges in trauma care is early identification and management of bleeding. The circulatory status of blunt trauma patients in the emergency room is evaluated using hemodynamic (HD) parameters. However, there is no consensus on which parameters to use. In this study, we evaluate the used terms and definitions in the literature for HD stability and compare those to the opinion of Dutch trauma team members. METHOD A systematic review was performed to collect the definitions used for HD stability. Studies describing the assessment and/or treatment of blunt trauma patients in the emergency room were included. In addition, an online survey was conducted amongst Dutch trauma team members. RESULTS Out of a total of 222, 67 articles were found to be eligible for inclusion. HD stability was defined in 70% of these articles. The most used parameters were systolic blood pressure and heart rate. Besides the variety of parameters, a broad range of corresponding cut-off points is noted. Despite some common ground, high inter- and intra-variability is seen for the physicians that are part of the Dutch trauma teams. CONCLUSION All authors acknowledge HD stability as the most important factor in the assessment and management of blunt trauma patients. There is, however, no consensus in the literature as well as none-to-fair consensus amongst Dutch trauma team members in the definition of HD stability. A trauma team ready to co-operate with consensus-based opinions together with a valid scoring system is in our opinion the best method to assess and treat seriously injured trauma patients.
Collapse
Affiliation(s)
- S A I Loggers
- Department of Trauma Surgery, VU University Medical Center, 7F029, De Boelelaan 1117, 1007 MB, Amsterdam, The Netherlands.
| | - T W A Koedam
- Department of Trauma Surgery, VU University Medical Center, 7F029, De Boelelaan 1117, 1007 MB, Amsterdam, The Netherlands
| | - G F Giannakopoulos
- Department of Trauma Surgery, VU University Medical Center, 7F029, De Boelelaan 1117, 1007 MB, Amsterdam, The Netherlands
| | - E Vandewalle
- Department of Emergency Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - M Erwteman
- Department of Anesthesiology, VU University Medical Center, Amsterdam, The Netherlands
| | - W P Zuidema
- Department of Trauma Surgery, VU University Medical Center, 7F029, De Boelelaan 1117, 1007 MB, Amsterdam, The Netherlands
| |
Collapse
|
13
|
Burkhardt M, Kristen A, Culemann U, Koehler D, Histing T, Holstein JH, Pizanis A, Pohlemann T. Pelvic fracture in multiple trauma: are we still up-to-date with massive fluid resuscitation? Injury 2014; 45 Suppl 3:S70-5. [PMID: 25284239 DOI: 10.1016/j.injury.2014.08.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Until today the mortality of complex pelvic trauma remains unacceptably high. On the one hand this could be attributed to a biological limit of the survivable trauma load, on the other hand side an ongoing inadequate treatment might be conceivable too. For the management of multiple trauma patients with life-threatening pelvic fractures, there is ongoing international debate on the adequate therapeutic strategy, e.g. arterial embolization or pelvic packing, as well as aggressive or restrained volume therapy. Whereas traditional pelvis-specific trauma algorithms still recommend massive fluid resuscitation, there is upcoming evidence that a restrained volume therapy in the preclinical setting may improve trauma outcomes. Less intravenous fluid administration may also reduce haemodilution and concomitant trauma-associated coagulopathy. After linking the data of the TraumaRegister DGU(®) and the German Pelvic Injury Register, for the first time, the initial fluid management for complex pelvic traumas as well as for different Tile/OTA types of pelvic ring fractures could be addressed. Unfortunately, the results could not answer the question of the adequate fluid resuscitation but confirmed the actuality of massive fluid resuscitation in the prehospital and emergency room setting. Low-volume resuscitation seems not yet accepted in practice in managing multiple trauma patients with pelvic fractures at least in Germany. Nevertheless, prevention of exsanguination and of complications like multiple organ dysfunction syndrome still poses a major challenge in the management of complex pelvic ring injuries. Even nowadays, fluid management for trauma, not only for pelvic fractures, remains a controversial area and further research is mandatory.
Collapse
Affiliation(s)
- Markus Burkhardt
- Department of Trauma, Orthopaedic and Hand Surgery, Protestant City Hospital, Großherzog-Friedrich-Straße 44, 66111 Saarbrücken, Germany.
| | - Alexander Kristen
- Department of Trauma, Orthopaedic and Hand Surgery, Protestant City Hospital, Großherzog-Friedrich-Straße 44, 66111 Saarbrücken, Germany.
| | - Ulf Culemann
- Department of Trauma Surgery, General Hospital Celle, Siemensplatz 4, 29223 Celle, Germany.
| | - Daniel Koehler
- Department of Trauma, Hand and Reconstructive Surgery, University of Saarland, Kirrbergerstraße 100, 66421 Homburg/Saar, Germany.
| | - Tina Histing
- Department of Trauma, Hand and Reconstructive Surgery, University of Saarland, Kirrbergerstraße 100, 66421 Homburg/Saar, Germany.
| | - Joerg H Holstein
- Department of Trauma, Hand and Reconstructive Surgery, University of Saarland, Kirrbergerstraße 100, 66421 Homburg/Saar, Germany.
| | - Antonius Pizanis
- Department of Trauma, Hand and Reconstructive Surgery, University of Saarland, Kirrbergerstraße 100, 66421 Homburg/Saar, Germany.
| | - Tim Pohlemann
- Department of Trauma, Hand and Reconstructive Surgery, University of Saarland, Kirrbergerstraße 100, 66421 Homburg/Saar, Germany.
| | | | | |
Collapse
|
14
|
Mutschler M, Paffrath T, Wölfl C, Probst C, Nienaber U, Schipper IB, Bouillon B, Maegele M. The ATLS(®) classification of hypovolaemic shock: a well established teaching tool on the edge? Injury 2014; 45 Suppl 3:S35-8. [PMID: 25284231 DOI: 10.1016/j.injury.2014.08.015] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Uncontrolled bleeding is the leading cause of shock in trauma patients and delays in recognition and treatment have been linked to adverse outcomes. For prompt detection and management of hypovolaemic shock, ATLS(®) suggests four shock classes based upon vital signs and an estimated blood loss in percent. Although this classification has been widely implemented over the past decades, there is still no clear prospective evidence to fully support this classification. In contrast, it has recently been shown that this classification may be associated with substantial deficits. A retrospective analysis of data derived from the TraumaRegister DGU(®) indicated that only 9.3% of all trauma patients could be allocated into one of the ATLS(®) shock classes when a combination of the three vital signs heart rate, systolic blood pressure and Glasgow Coma Scale was assessed. Consequently, more than 90% of all trauma patients could not be classified according to the ATLS(®) classification of hypovolaemic shock. Further analyses including also data from the UK-based TARN registry suggested that ATLS(®) may overestimate the degree of tachycardia associated with hypotension and underestimate mental disability in the presence of hypovolaemic shock. This finding was independent from pre-hospital treatment as well as from the presence or absence of a severe traumatic brain injury. Interestingly, even the underlying trauma mechanism (blunt or penetrating) had no influence on the number of patients who could be allocated adequately. Considering these potential deficits associated with the ATLS(®) classification of hypovolaemic shock, an online survey among 383 European ATLS(®) course instructors and directors was performed to assess the actual appreciation and confidence in this tool during daily clinical trauma care. Interestingly, less than half (48%) of all respondents declared that they would assess a potential circulatory depletion within the primary survey according to the ATLS(®) classification of hypovolaemic shock. Based on these observations, a critical reappraisal of the current ATLS(®) classification of hypovolaemic seems warranted.
Collapse
Affiliation(s)
- M Mutschler
- Department of Orthopedics, Trauma and Sportsmedicine, Cologne-Merheim Medical Center (CMMC), Private University Witten-Herdecke, Cologne, Germany.
| | - T Paffrath
- Department of Orthopedics, Trauma and Sportsmedicine, Cologne-Merheim Medical Center (CMMC), Private University Witten-Herdecke, Cologne, Germany
| | - C Wölfl
- Department of Trauma and Orthopedic Surgery, BG Hospital Ludwigshafen, Ludwigshafen, Germany
| | - C Probst
- Department of Orthopedics, Trauma and Sportsmedicine, Cologne-Merheim Medical Center (CMMC), Private University Witten-Herdecke, Cologne, Germany
| | - U Nienaber
- Academy for Trauma Surgery (AUC), Berlin, Germany
| | - I B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - B Bouillon
- Department of Orthopedics, Trauma and Sportsmedicine, Cologne-Merheim Medical Center (CMMC), Private University Witten-Herdecke, Cologne, Germany
| | - M Maegele
- Department of Orthopedics, Trauma and Sportsmedicine, Cologne-Merheim Medical Center (CMMC), Private University Witten-Herdecke, Cologne, Germany
| |
Collapse
|