Impact of a streamlined trauma management approach and determinants of mortality among hemodynamically unstable patients with severe multiple injuries: a before-and-after retrospective cohort study

Effect of access to the integrated treatment model for patients with multiple severe injuries in the Chinese population

AIMS

The aim of this study was to enhance the effectiveness of an integrated treatment model for patients with severe multiple injuries in China.

METHODS

In this study, we conducted a retrospective analysis of data from 110 patients with multiple severe injuries. These patients were divided into two groups based on the treatment model they received. The first group, called the MDTM group, received the integrated treatment model, which involved a multidisciplinary team-based approach. The second group, designated the TSM group, received the traditional specialist-based treatment model. The primary outcome measure was the survival rate of patients after treatment. Secondary outcomes included the time spent on hospital emergency treatment, the length of hospital stay, the mortality rate, and family satisfaction.

RESULTS

The survival rate of patients after treatment in the MDTM group (83.93%) was significantly greater than that in the TSM group (70.37%). Consequently, the mortality of patients after treatment in the MDTM group (16.07%) was significantly lower than that in the TSM group (29.63%). Furthermore, the MDTM group demonstrated significantly shorter durations of rescue efforts and shorter hospital stays. Additionally, family satisfaction was significantly greater in the MDTM group.

CONCLUSION

The integrated treatment model shows potential for optimizing outcomes for patients with multiple severe injuries and generating higher levels of family satisfaction. This model holds practical applicability in the context of China and may help alleviate the strained relationship between physicians and patients.

The impact of time to hemostatic intervention and delayed care for patients with traumatic hemorrhage: A systematic review

BACKGROUND

Uncontrolled bleeding is a common cause of preventable mortality in trauma. While it is intuitive that delays to hemostasis may lead to worse outcomes, the impacts of these delays remain incompletely explored. This systematic review aimed to characterize the extant definitions of delayed hemostatic intervention and to quantify the impacts of delays on clinical outcomes.

METHODS

We searched EMBASE, MEDLINE, and Web of Science from inception to August 2022. Studies defining "delayed intervention" and those comparing times to intervention among adults presenting to hospital with blunt or penetrating injuries who required major hemostatic intervention were eligible. The coprimary outcomes were mortality and the definition of delay to hemostasis used. Secondary outcomes included units of packed red blood cells received, length of stay in hospital, and length of stay in intensive care.

RESULTS

We identified 2,050 studies, with 24 studies including 10,168 patients meeting the inclusion criteria. The majority of studies were retrospective observational cohort studies, and most were at high risk of bias. A variety of injury patterns and hemostatic interventions were considered, with 69.6% of studies reporting a statistically significant impact of increased time to intervention on mortality. Definitions of delayed intervention ranged from 10 minutes to 4 hours. Conflicting data were reported for impact of time on receipt of blood products, while one study found a significant impact on intensive care length of stay. No studies assessed length of stay in hospital.

CONCLUSION

The extant literature is heterogeneous with respect to injuries included, methods of hemostasis employed, and durations of delay examined. While the majority of the included studies demonstrated a statistically significant relationship between time to intervention and mortality, an evidence-informed definition of delayed intervention for bleeding trauma patients at large has not been solidified. In addition, standardized research is needed to establish targets, which could reduce morbidity and mortality.

LEVEL OF EVIDENCE

Systematic Review; Level IV.

Team Approach: The Unstable Trauma Patient

» A multidisciplinary, integrated, and synergistic team approach to the unstable polytrauma patient is critical to optimize outcomes, minimize morbidity, and reduce mortality.» The use of Advanced Trauma Life Support protocols helps standardize the assessment and avoid missing critical injuries» Effective and open dialog with consulting specialists is paramount for effective team-based care.» Orthopaedic surgeons should play an important role in the rapid assessment of potentially life-threatening and/or limb-threatening injuries including pelvic ring disruption, open fractures with substantial blood loss, and dysvascular limbs.

Blood management practices during rapid transfer of urgent trauma patients pre- and post-implementation of ROTEM®-guided transfusion

Objective

The ‘Red Blanket’ protocol fast tracks trauma patients with severe blood loss to the designated trauma operating theatre directly from the hospital helipad or Emergency Department. This study aimed to assess the impact of patient blood management (PBM) strategies on severely injured trauma patients treated under the ‘Red Blanket’ protocol at a quaternary referral hospital.

Methods

This retrospective review was conducted on all urgent trauma cases that were treated under the ‘Red Blanket’ protocol in a ten-year period between January 2007 and December 2017. The use of blood products and patient outcomes was compared between the 3.5-year periods pre- and post-ROTEM® implementation on 30th June 2014 (Jan 2011-June 2014 versus July 2014-Dec 2017).

Results

During the study period, 120 trauma patients were treated under the ‘Red Blanket’ protocol at our institution. Intention to treat analysis showed a reduction in fresh frozen plasma usage following the introduction of ROTEM®-guided transfusion. Furthermore, subgroup analysis suggested reduced blood product usage in patients who survived.

Conclusions

Patient blood management is a coordinated package of systems and tools, including education, patient logistics, anaemia management, intraoperative cell salvage, rotational thromboelastometry and massive transfusion protocols that together conserve blood products and improve outcomes. The implementation of ROTEM®-guided transfusion demonstrated a reduction in fresh frozen plasma usage.

Is resuscitative endovascular balloon occlusion of the aorta for computed tomography diagnosis feasible or not? A Japanese single-center, retrospective, observational study

BACKGROUND

Advances in medical equipment have resulted in changes in the management of severe trauma. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in this scenario is still unclear. This study aimed to evaluate the usage of REBOA and utility of computed tomography (CT) in the setting of aortic occlusion in our current trauma management.

METHODS

This Japanese single-tertiary center, retrospective, and observational study analyzed 77 patients who experienced severe trauma and persistent hypotension between October 2014 and March 2020.

RESULTS

All patients required urgent hemostasis. Twenty patients underwent REBOA, 11 underwent open aortic cross-clamping, and 46 did not undergo aortic occlusion. Among patients who underwent aortic occlusion, 19 patients underwent prehemostasis CT, and 7 patients underwent operative exploration without prehemostasis CT for identifying active bleeding sites. The 24-hour and 28-day survival rates in patients who underwent CT were not inferior to those in patients who did not undergo CT (24-hour survival rate, 84.2% vs. 57.1%; 28-day survival rate, 47.4% vs. 28.6%). Moreover, the patients who underwent CT had less discordance between primary hemostasis site and main bleeding site compared with patients who did not undergo CT (5% vs. 71.4%, p = 0.001). In the patients who underwent prehemostasis CT, REBOA was the most common approach of aortic occlusion. Most of the bleeding control sites were located in the retroperitoneal space. There were many patients who underwent interventional radiology for hemostasis.

CONCLUSION

In a limited number of patients whose cardiac arrests were imminent and in whom no active bleeding sites could be clearly identified without CT findings, REBOA for CT diagnosis may be effective; however, further investigations are needed.

LEVEL OF EVIDENCE

Therapeutic/care management study, level V.