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Schoenfeld DW, Rosen CL, Harris T, Thomas SH. Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis. Acad Emerg Med 2024; 31:590-598. [PMID: 38517320 DOI: 10.1111/acem.14882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/06/2024] [Accepted: 01/10/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products. METHOD The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified. RESULTS In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19). CONCLUSIONS Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.
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Affiliation(s)
- David W Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Carlo L Rosen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Tim Harris
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, Massachusetts, USA
- Blizard Institute for Neuroscience, Surgery, and Trauma, Barts and The London School of Medicine, London, UK
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2
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Abuelazm M, Rezq H, Mahmoud A, Tanashat M, Salah A, Saleh O, Morsi S, Abdelazeem B. The efficacy and safety of pre-hospital plasma in patients at risk for hemorrhagic shock: an updated systematic review and meta-analysis of randomized controlled trials. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02461-7. [PMID: 38367091 DOI: 10.1007/s00068-024-02461-7] [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: 11/08/2023] [Accepted: 01/22/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND AND OBJECTIVE Plasma is a critical element in hemostatic resuscitation post-injury, and its prompt administration within the prehospital setting may reduce the complications resulting from hemorrhage and shock. Our objective is to assess the efficacy and safety of prehospital plasma infusion in patients susceptible to hemorrhagic shock. METHODS We conducted our study by aggregating randomized controlled trials (RCTs) sourced from PubMed, EMBASE, Scopus, Web of Science, and Cochrane CENTRAL up to January 29, 2023. Quality assessment was implemented using the Cochrane RoB 2 tool. Our study protocol is registered in PROSPERO under ID: CRD42023397325. RESULTS Three RCTs with 760 individuals were included. There was no difference between plasma infusion and standard care groups in 24-h mortality (P = 0.11), 30-day mortality (P = 0.12), and multiple organ failure incidences (P = 0.20). Plasma infusion was significantly better in the total 24-h volume of PRBC units (P = 0.03) and INR on arrival (P = 0.009). For all other secondary outcomes evaluated (total 24-h volume of packed FFP units, total 24-h volume of platelets units, massive transfusion, vasopressor need during the first 24 h, any adverse event, acute lung injury, transfusion reaction, and sepsis), no significant differences were observed between the two groups. CONCLUSION Plasma infusion in trauma patients at risk of hemorrhagic shock does not significantly affect mortality or the incidence of multiple organ failure. However, it may lead to reduced packed red blood cell transfusions and increased INR at hospital arrival.
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Affiliation(s)
| | - Hazem Rezq
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
| | | | | | | | - Othman Saleh
- Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Samah Morsi
- Department of Radiation Oncology, UT Texas MD Anderson, Houston, TX, USA
| | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, Morgantown, WV, USA
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3
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Gianola S, Castellini G, Biffi A, Porcu G, Napoletano A, Coclite D, D'Angelo D, Di Nitto M, Fauci AJ, Punzo O, Iannone P, Chiara O. Volume replacement in the resuscitation of trauma patients with acute hemorrhage: an umbrella review. Int J Emerg Med 2023; 16:87. [PMID: 38036955 PMCID: PMC10687916 DOI: 10.1186/s12245-023-00563-4] [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: 07/06/2023] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND The use of intravenous fluid therapy in patients with major trauma in prehospital settings is still controversial. We conducted an umbrella review to evaluate which is the best volume expansion in the resuscitation of a hemorrhagic shock to support the development of major trauma guideline recommendations. METHODS We searched PubMed, Embase, and CENTRAL up to September 2022 for systematic reviews (SRs) investigating the use of volume expansion fluid on mortality and/or survival. Quality assessment was performed using AMSTAR 2 and the Certainty of the evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS We included 14 SRs investigating the effects on mortality with the comparisons: use of crystalloids, blood components, and whole blood. Most SRs were judged as critically low with slight overlapping of primary studies and high consistency of results. For crystalloids, inconsistent evidence of effectiveness in 28- to 30-day survival (primary endpoint) was found for the hypertonic saline/dextran group compared with isotonic fluid solutions with moderate certainty of evidence. Pre-hospital blood component infusion seems to reduce mortality, however, as the certainty of evidence ranges from very low to moderate, we are unable to provide evidence to support or reject its use. The blood component ratio was in favor of higher ratios among all comparisons considered with moderate to very low certainty of evidence. Results about the effects of whole blood are very uncertain due to limited and heterogeneous interventions in studies included in SRs. CONCLUSION Hypertonic crystalloid use did not result in superior 28- to 30-day survival. Increasing evidence supports the scientific rationale for early use of high-ratio blood components, but their use requires careful consideration. Preliminary evidence is very uncertain about the effects of whole blood and further high-quality studies are required.
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Affiliation(s)
- Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Annalisa Biffi
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- Department of Statistics and Quantitative Methods, National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
| | - Antonello Napoletano
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Daniela Coclite
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Daniela D'Angelo
- Azienda Sanitaria Locale Roma/6, Via Borgo Garibaldi, 12 00041 Albano Laziale, Rome, Italy.
- CECRI Evidence-Based Practice Group for Nursing Scholarship: A JBI Affiliated Group, Rome, Italy.
| | - Marco Di Nitto
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Alice Josephine Fauci
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Ornella Punzo
- Centro Nazionale Per L'Eccellenza Clinica, La Qualità E La Sicurezza Delle Cure, Istituto Superiore Di Sanità, Rome, Italy
| | - Primiano Iannone
- Dipartimento Di Medicina Interna, Azienda USL, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Osvaldo Chiara
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Milano, Piazza Ospedale Maggiore, Milan, Italy
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4
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Katzenschlager S, Obermaier M, Kuhner M, Spöttl W, Dietrich M, Weigand MA, Weilbacher F, Popp E. [Focus emergency medicine 2022/2023-Summary of selected studies in emergency medicine]. DIE ANAESTHESIOLOGIE 2023; 72:809-820. [PMID: 37725144 DOI: 10.1007/s00101-023-01330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 09/21/2023]
Affiliation(s)
- S Katzenschlager
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - M Obermaier
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Kuhner
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - W Spöttl
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - F Weilbacher
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - E Popp
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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5
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Maegele M, Lier H, Hossfeld B. Pre-Hospital Blood Products for the Care of Bleeding Trauma Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:670-676. [PMID: 37551452 PMCID: PMC10644958 DOI: 10.3238/arztebl.m2023.0176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/13/2023] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Controversy surrounds the administration of blood products to severely traumatized patients before they arrive in the hospital in order to compensate for early blood loss and/or to correct coagulation disturbances that arise shortly after the traumatic event. A number of terrestrial and air rescue services have begun to provide this kind of treatment. METHODS This review is based on articles using the PICO framework, published from January 2001 to January 2021, that were retrieved by a selective search, with structured searching strategies and searching bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos. A demand analysis was carried out on the basis of data from the trauma registry of the German Society of Trauma Surgery (TR-DGU) and practical experience from program development and implementation was provided by the Bundeswehr Hospital Ulm. RESULTS The currently available evidence on the pre-hospital administration of blood products in the early treatment of severely injured patients is based largely on retrospective, single-center case series. Two randomized controlled trials (RCTs) concerning the early use of fresh frozen plasma concentrates have yielded partly conflicting results. Three further RCTs on the use of lyophilized plasma (lyplas), lyplas plus erythrocyte concentrate, or whole blood likewise revealed non-uniform effects on short-term and intermediate-term mortality. Our demand analysis based on data from the TR-DGU showed that 300 to 1800 patients per year in Germany could benefit from the pre-hospital administration of blood products. This might be indicated in patients who have systolic hypotension (<100 mmHg) in combination with a suspected or confirmed hemorrhage, as well as pathological shock parameters in the point-of-care diagnostic testing performed on the scene (serum base excess ≤ -2.5 mmol/L and/or serum lactate concentration >4 mmol/L). CONCLUSION The studies that have been published to date yield no clear evidence either for or against the early pre-hospital administration of blood products. Any treatment of this kind should be accompanied by scientific evaluation.
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Affiliation(s)
- Marc Maegele
- *Joint first authors
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Cologne
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Campus Cologne-Merheim, Cologne
| | - Heiko Lier
- *Joint first authors
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne
| | - Björn Hossfeld
- Department of Anaesthesiology and Intensive Care Medicine, Armed Forces Hospital Ulm, Ulm
- Rescue transport helicopter (RTH) „Christoph 22“ Ulm, ADAC-Air Rescue, Ulm
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6
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Mitra B, Meadley B, Bernard S, Maegele M, Gruen RL, Bradley O, Wood EM, McQuilten ZK, Fitzgerald M, St. Clair T, Webb A, Anderson D, Reade MC. Pre-hospital freeze-dried plasma for critical bleeding after trauma: A pilot randomized controlled trial. Acad Emerg Med 2023; 30:1013-1019. [PMID: 37103482 PMCID: PMC10946458 DOI: 10.1111/acem.14745] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/06/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Transfusion of a high ratio of plasma to packed red blood cells (PRBCs), to treat or prevent acute traumatic coagulopathy, has been associated with survival after major trauma. However, the effect of prehospital plasma on patient outcomes has been inconsistent. The aim of this pilot trial was to assess the feasibility of transfusing freeze-dried plasma with red blood cells (RBCs) using a randomized controlled design in an Australian aeromedical prehospital setting. METHODS Patients attended by helicopter emergency medical service (HEMS) paramedics with suspected critical bleeding after trauma managed with prehospital RBCs were randomized to receive 2 units of freeze-dried plasma (Lyoplas N-w) or standard care (no plasma). The primary outcome was the proportion of eligible patients enrolled and provided the intervention. Secondary outcomes included preliminary data on effectiveness, including mortality censored at 24 h and at hospital discharge, and adverse events. RESULTS During the study period of June 1 to October 31, 2022, there were 25 eligible patients, of whom 20 (80%) were enrolled in the trial and 19 (76%) received the allocated intervention. Median time from randomization to hospital arrival was 92.5 min (IQR 68-101.5 min). Mortality may have been lower in the freeze-dried plasma group at 24 h (RR 0.24, 95% CI 0.03-1.73) and at hospital discharge (RR 0.73, 95% CI 0.24-2.27). No serious adverse events related to the trial interventions were reported. CONCLUSIONS This first reported experience of freeze-dried plasma use in Australia suggests prehospital administration is feasible. Given longer prehospital times typically associated with HEMS attendance, there is potential clinical benefit from this intervention and rationale for a definitive trial.
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Affiliation(s)
- Biswadev Mitra
- Alfred Health Emergency ServicesMelbourneVictoriaAustralia
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Ben Meadley
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
| | - Stephen Bernard
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
- Department of Intensive CareThe Alfred HospitalMelbourneVictoriaAustralia
| | - Marc Maegele
- Department of Traumatology and Orthopaedic SurgeryCologne‐Merheim Medical CentreCologneGermany
- Institute for Research in Operative Medicine, Experimental/Clinical Research UnitUniversity Witten‐HerdeckeCologneGermany
| | - Russell L. Gruen
- College of Health and MedicineAustralian National UniversityCanberraAustralian Capital TerritoryAustralia
| | | | - Erica M. Wood
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of HaematologyMonash HealthMelbourneVictoriaAustralia
| | - Zoe K. McQuilten
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of HaematologyMonash HealthMelbourneVictoriaAustralia
| | - Mark Fitzgerald
- Trauma ServiceThe Alfred HospitalMelbourneVictoriaAustralia
- Central Clinical SchoolMonash UniversityMelbourneVictoriaAustralia
- National Trauma Research InstituteMelbourneVictoriaAustralia
| | - Toby St. Clair
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
| | - Andrew Webb
- Department of HaematologyThe Alfred HospitalPrahran, MelbourneVictoriaAustralia
| | - David Anderson
- Department of ParamedicineMonash UniversityFrankstonVictoriaAustralia
- Ambulance VictoriaDoncasterVictoriaAustralia
- Department of Intensive CareThe Alfred HospitalMelbourneVictoriaAustralia
| | - Michael C. Reade
- School of Public Health & Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Faculty of MedicineRoyal Brisbane and Women's Hospital, The University of QueenslandHerstonQueenslandAustralia
- Joint Health Command, Australian Defence ForceCanberraAustralian Capital TerritoryAustralia
- Department of Intensive Care MedicineRoyal Brisbane and Women's HospitalBrisbaneQueenslandAustralia
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7
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Metcalf M, Turnock M, Hall P, Hammett O, Cowburn P, Godfrey T. Pre-hospital blood products for hazardous area response team paramedics: A service evaluation to inform decisions on future practice. TRAUMA-ENGLAND 2023. [DOI: 10.1177/14604086231163364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
Aim To identify the number of incidents, over a 1-year period in a single UK Ambulance Service Trust, where patients attended by Hazardous Area Response Team (HART) paramedics where eligible to receive Pre-hospital Blood Products (PHBP) but did not due to the unavailability of a suitably trained clinician. Methods This was a Service Evaluation using a three-stage method of filtering data to reduce bias and improve accuracy when identifying eligible cases. These stages consisted of an initial data request, a peer review filtering stage and then finally an Expert Consensus Panel review of cases to determine whether PHBP should have been administered. Results The consensus group considered 14 cases that would have ‘Likely’ or ‘Certainly’ have received PHBP if a suitably trained clinician was available on scene. Twelve cases involved a traumatic cause whilst the remaining two were medical. Similarly, 12 cases involved patients with spontaneous circulation whilst two patients had no pulse. South Western Ambulance Service Foundation Trust (SWASFT) Bristol HART attended eight and Exeter HART six of these cases. Conclusion This study reveals that across the South West of England, there were a number of patients, being attended by HART, who may potentially benefit from PHBP but are not receiving this intervention due to the unavailability of a suitably trained clinician. This could be far more in the event of a multi or mass-casualty event. HART paramedic access to PHBPs would enable more patients to access a potentially lifesaving treatment and contribute to narrowing the care gap identified in the Manchester Arena Inquiry. The authors recommend that a local pilot trial is undertaken to explore whether a HART PHBP service is feasible, sustainable, cost-effective, appropriate, and safe.
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Affiliation(s)
- Matthew Metcalf
- Hazardous Area Response Team, South Western Ambulance Service Foundation Trust, Bristol, UK
| | - Matthew Turnock
- Hazardous Area Response Team, South Western Ambulance Service Foundation Trust, Bristol, UK
| | - Pippa Hall
- Hazardous Area Response Team, South Western Ambulance Service Foundation Trust, Bristol, UK
| | - Owen Hammett
- Dorset and Somerset Air Ambulance, South Western Ambulance Service NHS Foundation Trust, Wellington, UK
- South Western Ambulance Service Foundation Trust, Exeter, UK
| | - Philip Cowburn
- South Western Ambulance Service Foundation Trust, Exeter, UK
- Emergency Department, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- National Ambulance Response Unit, College of Policing, UK
- Great Western Air Ambulance Charity, South Western Ambulance Service NHS Foundation Trust, Bristol, UK
| | - Timothy Godfrey
- South Western Ambulance Service Foundation Trust, Exeter, UK
- Great Western Air Ambulance Charity, South Western Ambulance Service NHS Foundation Trust, Bristol, UK
- Emergency Department, North Bristol NHS Trust, Bristol, UK
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8
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 120] [Impact Index Per Article: 120.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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9
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Herbstreit F, Grissom TE, Pivalizza EG. Viscoelastic Hemostatic Assays in Trauma: And the Winner Is…. Anesth Analg 2022; 134:19-20. [PMID: 34908542 DOI: 10.1213/ane.0000000000005765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Frank Herbstreit
- From the Department of Anesthesiology and Intensive Care Medicine, University Duisburg-Essen, Faculty of Medicine, University Hospital Essen, Essen, Germany
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Evan G Pivalizza
- Department of Anesthesiology, University of Texas, Health Science Center, McGovern Medical School, Houston, Texas
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10
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Harris D, Martin D, Bednarz J, Ellis DY. Acute traumatic coagulopathy and the relationship to prehospital care and on-scene red blood cell transfusion. Emerg Med Australas 2021; 33:834-840. [PMID: 33556992 DOI: 10.1111/1742-6723.13734] [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: 07/10/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To identify the incidence of acute traumatic coagulopathy (ATC) in trauma patients presenting to the Royal Adelaide Hospital, analyse prehospital contributors, including red blood cell transfusion and assess the clinical significance of ATC. METHODS A retrospective database review was undertaken using conventional coagulation assays and viscoelastic testing (ROTEM) for diagnosis of ATC. RESULTS Baseline ATC incidence is 10% in trauma patients, increasing to over 80% among those where the prehospital team has attended and given a transfusion of red cells. ATC was significantly associated with higher severity of trauma (odds ratio [OR] 1.11, P < 0.0001), prehospital (OR 11.8, P < 0.0001) and in-hospital blood transfusions (OR 17.9, P < 0.0001), and massive transfusions (P < 0.001). CONCLUSIONS Prehospital blood transfusions are given to the most severely injured trauma patients and the incidence of ATC in this group is more than 80%. There is an association with prehospital blood transfusion and increased ATC in part related to patient selection and severity of trauma, with the contribution of red cell transfusions to ATC unclear. This association should allow earlier identification of patients at increased risk of ATC to ensure rapid correction of coagulopathy to decrease the morbidity and mortality of trauma.
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Affiliation(s)
- Daniel Harris
- Trauma Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Emergency Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.,Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia.,MedSTAR Emergency Medical Retrieval, SA Ambulance Service, Adelaide, South Australia, Australia
| | - Daniel Martin
- MedSTAR Emergency Medical Retrieval, SA Ambulance Service, Adelaide, South Australia, Australia.,School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia
| | - Jana Bednarz
- Adelaide Health Technology Assessment, The University of Adelaide, Adelaide, South Australia, Australia
| | - Daniel Y Ellis
- Trauma Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Emergency Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,MedSTAR Emergency Medical Retrieval, SA Ambulance Service, Adelaide, South Australia, Australia.,School of Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia
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11
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Breeze J, Bowley DM, Naumann DN, Marsden MER, Fryer RN, Keene D, Ramasamy A, Lewis EA. Torso body armour coverage defined according to feasibility of haemorrhage control within the prehospital environment: a new paradigm for combat trauma protection. BMJ Mil Health 2020; 168:399-403. [PMID: 33109734 DOI: 10.1136/bmjmilitary-2020-001582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 11/03/2022]
Abstract
Developments in military personal armour have aimed to achieve a balance between anatomical coverage, protection and mobility. When death is likely to occur within 60 min of injury to anatomical structures without damage control surgery, then these anatomical structures are defined as 'essential'. However, the medical terminology used to describe coverage is challenging to convey in a Systems Requirements Document (SRD) for acquisition of new armour and to ultimately translate to the correct sizing and fitting of personal armour. Many of those with Ministry of Defence responsible for the procurement of personal armour and thereby using SRDs will likely have limited medical knowledge; therefore, the potentially complex medical terminology used to describe the anatomical boundaries must be translated into easily recognisable and measurable external landmarks. We now propose a complementary classification for ballistic protection coverage, termed threshold and objective, based on the feasibility of haemorrhage control within the prehospital environment.
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Affiliation(s)
- Johno Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK .,Department of Bioengineering, Imperial College London, London, UK
| | - D M Bowley
- Surgery, 16 Medical Regiment, Colchester, UK
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - M E R Marsden
- Department of General Surgery, Queen Alexandra Hospital, Cosham, UK
| | | | - D Keene
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - A Ramasamy
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK.,Trauma and Orthopaedics, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, UK
| | - E A Lewis
- Defence Equipment and Support, Ministry of Defence Abbey Wood, Bristol, UK
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