Traumatic hemorrhage and chain of survival

Cotton gauze fabricated with hydro-stable Zn-MOF enables hemostasis acceleration, antibacterial activity, and wound regeneration

Cotton has long been regarded as a naturally abundant and clinically indispensable material for medical textiles. Cotton gauze, a cornerstone material in wound management due to its inherent fluid absorption capacity, faces limitations in simultaneously addressing hemorrhage and infection. In this work, we developed a multifunctional wound dressing by functionalizing commercial cotton gauze with a tannic acid-assisted layer-by-layer assembly strategy to immobilize zinc-based metal-organic frameworks (Zn-BDC). The resulting cg@PTA@Zn-BDC-5 dressing synergizes the intrinsic advantages of cotton textiles with advanced functionalities, achieving a 76.4 % reduction in blood clotting time through Zn2+-activated coagulation cascades and enhanced platelet adhesion (73.6 % red blood cell attachment). Crucially, the modified cotton gauze also exhibits broad-spectrum antibacterial activity (>95 % inhibition against E. coli and S. aureus), addressing the dual demands of hemostasis and infection prevention unmet by conventional cotton dressings. Biosafety assessments confirm clinical viability (<3 % hemolysis, ~90 % cell viability). In vivo studies demonstrate accelerated wound closure through Zn2+-mediated collagen deposition and anti-inflammatory modulation, with the cotton scaffold synergistically enables therapeutic amplification due to its mechanical compliance, breathability and fluid management capabilities.

A comprehensive comparison on hemostatic performance of natural and synthetic nano-clay minerals embedded in modified cellulose-based sponge for non-compressible massive bleedings

Natural clay minerals demonstrate high performance in controlling severe hemorrhage and have a low stimulatory impact, their large particle size and potential risk of thrombosis are considered significant drawbacks compared to synthetic nano-clay minerals. Conversely, complex and costly synthesis process of synthetic nano-clay minerals limits their scalability for commercial applications. Herein, a novel approach using planetary ball milling following glow discharge plasma irradiation was applied to convert natural kaolinite into pseudohexagonal-shaped kaolinite nanoparticles (30 to 150 nm). Triple-network carboxymethyl cellulose sponges, crosslinked with nano kaolinite and laponite as natural and synthetic nano-clay minerals, Ca2+, citric acid, was engineered. Results demonstrate that plasma-treated natural nano-clay minerals exhibit superior hemostatic performance compared to synthetic nano-clay minerals, as confirmed by in-vitro hemostatic evaluations (P < 0.01). In vivo hemostatic evaluations demonstrate that both synthetic and plasma-treated natural nano-clay minerals sponges exhibit superior hemostatic performance (hemostasis time and blood loss) in a rat femoral artery bleeding model compared to commercial hemostatic sponges (P-values <0.001). The hematological, pathological, and biochemical parameter tests, revealed no systemic or local inflammatory response. Consequently, innovative treatment of natural clay minerals offers a viable solution by producing low-risk materials with reduced synthesis costs compared to synthetic nano-clay minerals.

Improving prediction accuracy of hospital arrival vital signs using a multi-output machine learning model: a retrospective study of JSAS-registry data

BACKGROUND

Critically ill patients can deteriorate rapidly; therefore, prompt prehospital interventions and seamless transition to in-hospital care upon arrival are crucial for improving survival. In Japan, helicopter emergency medical services (HEMS) complement general emergency medical services (GEMS) by providing on-site care, reducing transport times, and aiding facility selection. Vital signs at hospital arrival determine initial management, but existing models are poor at predicting them, especially in patients receiving continuous interventions from both GEMS and HEMS. Therefore, we developed a machine-learning model to accurately predict the actual values of vital signs at hospital arrival using limited patient characteristic data and prehospital vital signs.

METHODS

Using data from the Japanese Society for Aeromedical Services registry, we retrospectively analyzed data from patients aged ≥18 years transported by HEMS between April 2020 and March 2022. Patients with cardiac arrest during transport, missing vital signs, and data inconsistencies were excluded. The predictive model used prehospital vital signs from GEMS and HEMS contact times, demographic characteristics, and intervention information. The primary outcome was the actual values of vital signs measured at hospital arrival. After data preprocessing, we constructed a deep neural network multi-output regression model using Bayesian optimization. Model performance was assessed by comparing the predicted values with the actual hospital arrival measurements using mean absolute error, R² score, residual standard deviation, and Spearman's correlation coefficient. Additionally, the NN model's performance was compared with alternative methods, namely HEMS contact values and change-based predictions derived solely from prehospital data.

RESULTS

The study included 10,478 patients (median age 70 years; 69% male). The model achieved mean absolute errors of 7.1 bpm for heart rate, 15.7 mmHg for systolic blood pressure, 10.8 mmHg for diastolic blood pressure, 2.9 breaths/min for respiratory rate, and 0.62 points for Glasgow Coma Scale score. The Spearman's correlation coefficients ranged from 0.54 to 0.86. The model outperformed other methods, especially for R² scores and residual standard deviations, demonstrating its superior ability to predict actual vital signs values.

CONCLUSION

The multi-output regression model accurately predicted the actual values of vital signs measured at hospital arrival using limited prehospital information, demonstrating the effectiveness of advanced modeling techniques.

Fabrication of pullulan-chitosan fiber membranes for enhanced hemostatic applications

Pullulan-based fibers blended with chitosan (Chi) were developed using a rotational spinning method for potential biomedical applications. Aqueous precursor formulations containing 15 % by weight in pullulan and varying Chi concentrations (6 % and 7 %) were optimized to produce nanofibers at elevated temperatures and rotational speeds exceeding 7 k rpm. The highest fiber production yields of approximately 90 % and 65 % were achieved at 13 k rpm for the 6 % and 7 % Chi formulations, respectively. The pullulan-chitosan fibers were characterized by scanning electron microscopy, Fourier transform infrared spectroscopy, dynamic mechanical analyzer, powder X-ray diffraction, and rheological property measurements. Morphological analyses revealed nanometric fiber diameters and a decrease in bead formation with increasing rotational speeds. Thermal stability studies, conducted via thermogravimetric and differential thermal analyses, showed that the composite fibers exhibited intermediate degradation behaviors between their individual polymer components, indicating good integration of Chi into the pullulan matrix. Elemental analysis confirmed the successful incorporation of Chi into the fibers, with nitrogen content closely matching theoretical predictions. Functional assessments demonstrated the hemocompatibility of the Pull-Chi fibers with hemolysis rates below 1 %. Additionally, the fibers exhibited superior hemostatic potential, effectively promoting blood clotting in vitro testing. These findings underscore the promise of Pull-Chi fibers as multifunctional biomaterials for applications in wound healing and tissue engineering. Future studies involving animal models are warranted to validate their clinical potential.

Effect of Early Vasopressin Administration in Refractory Hemorrhagic Shock

BACKGROUND

Hemorrhagic shock management includes controlling bleeding and blood product replacement; however, vasopressor therapy may be required to maintain adequate perfusion. Studies have shown the potential benefits of early vasopressin use, but there is limited evidence of its clinical utility.

OBJECTIVE

This study aims to evaluate the efficacy of early vasopressin administration in trauma patients with refractory hemorrhagic shock.

METHODS

This retrospective cohort study included adult trauma patients who received more than one blood product. The primary outcome was 28-day alive and vasopressor-free days. Secondary outcomes included blood product administration, 28-day alive and ventilator-free days, and intensive care unit and hospital length of stay (LOS). Safety outcomes included the incidence of renal replacement therapy, venous thromboembolism, and fluid overload.

RESULTS

Overall, 37 patients were included, with seven (19%) in the vasopressin group and 30 (81%) in the norepinephrine group. The study population included primarily male patients (n = 29, 78%) with blunt injuries (n = 24, 65%) and a median Injury Severity Score of 26 [IQR 17.0-34.0]. There was no difference in the primary outcome between the vasopressin and norepinephrine groups (median 25.5 [IQR 22.7-26.7] vs 26.2 days [IQR 22.7-26.7], p = .985). All secondary and safety outcomes were similar, except that the vasopressin group was associated with a longer hospital LOS (20 [IQR 18-27] vs. 13 days [IQR 8-20], p = .036).

CONCLUSION

Early vasopressin administration was not associated with a significant difference in 28-day alive and vasopressor-free days. However, this study was limited by its small sample size, and further studies are needed.

Recent Trends in the Application of Cellulose-Based Hemostatic and Wound Healing Dressings

Rapid hemostasis and wound healing are crucial severe trauma treatment. Natural mechanisms often prove insufficient, spurring research for innovative biomaterials. This review focuses on cellulose-based materials, which are promising due to their absorbency, biocompatibility, and processability. The novelty lies in exploring how these materials promote clotting and tissue regeneration. They operate via extrinsic and intrinsic mechanisms. Extrinsically, they create a matrix at the wound to activate coagulation; intrinsically, they maintain clotting factors. Additionally, they aid healing through physical, chemical, and biological means, such as maintaining moisture, incorporating antimicrobial agents, and stimulating cell activity. The innovative fabrication strategies include material selection and chemical modification. Techniques like oxidation enhance performance. Structural engineering methods like freeze-drying and 3D printing optimize porosity and alignment. Cellulose-based dressings are versatile and effective in various forms. They address different wound needs and show benefits like rapid coagulation and tissue repair. This review also covers challenges and future trends, emphasizing the need to enhance mechanical properties and biodegradability. Further, new technologies offer potential improvements to the nanocomposites. Overall, continued research on cellulose-based dressing is vital, and unlocking their potential could revolutionize wound care, providing suitable solutions for trauma management.

Blood product use in paediatric trauma: lessons from the TARN data

BACKGROUND

Trauma contributes significantly to childhood morbidity and mortality. Uncontrolled haemorrhage leading to cardiovascular collapse remains the leading cause of preventable death in paediatric trauma. Evidence to support the early and accurate identification of paediatric trauma patients requiring blood products is growing. Consensus guidelines advocating for more liberal blood product use based on the concept of damage control resuscitation and the introduction of risk predictor tools to identify children requiring resuscitation with blood products may have altered use in recent years. We aimed to identify trends in blood product prescribing practice in paediatric trauma resuscitation over the last decade.

METHODS

In this retrospective, observational study, data were abstracted from Trauma Audit Research Network (TARN) from sites in England, Wales and Northern Ireland over a 10-year period (2012-2021). Eligible cases were defined as injured children or young people aged less than 16 years who received blood products, including in the prehospital environment.

RESULTS

During the study period, 2.5% (n=678) of injured children received blood products within 24 hours of hospital arrival, including the prehospital environment. Blood product administration over the study period remained largely unchanged (p=0.190). Over the 10-year period, we saw a significant increase in blood product use among paediatric trauma patients of increasing age and those with penetrating injuries (p<0.03). By contrast, there was a decrease in blood product use across the same 10-year period among paediatric trauma related to road traffic collisions (p=0.01). On analysing the paediatric trauma population that received blood products, the distribution across locations can be seen as follows: 60.5% received blood products at the scene of the incident, 25% in the ED and 12.8% in critical care settings. The most common blood product given was packed red blood cells (84%), with fresh frozen plasma, platelets and cryoprecipitate administered in 9.7%, 2.4% and 1.6% of cases, respectively.

CONCLUSION

UK trauma centres have not significantly changed blood product use in paediatric trauma over the last decade. Monitoring and understanding national blood product use in paediatric trauma is integral to understanding trends and current practice.

Managing pelvic fractures with haemorrhage using a multidisciplinary team approach: a case report from India

Pelvic fractures with haemorrhage are associated with high mortality and morbidity. This article describes the case of a 21-year-old man who was admitted to the emergency department of a hospital in India with a pelvic fracture and haemorrhage following a road traffic accident. It highlights the crucial role of nurses in coordinating the initial assessment, diagnostic investigations and treatment as well as the ongoing management of patients presenting with such injuries. Timely interventions by a multidisciplinary team are critical for preventing hypovolaemic shock, reducing mortality and limiting disability.

Applications of Hydrogels in Emergency Therapy

Interest in developing new, effective materials for emergency hemostasis and wound healing is steadily increasing, particularly for use in emergency, surgical, and military situations. Hydrogels, with their unique retention, swelling, and biocompatibility properties, have emerged as essential materials in emergency therapy. This review provides a comprehensive examination of recent hydrogel applications in acute medical scenarios, including hemostasis, wound management, drug delivery, soft tissue replacement, and tissue engineering. We discuss the physicochemical properties that make hydrogels suitable for rapid response situations, such as their tunable mechanical strength, adhesiveness, responsiveness to environmental stimuli, and ability to encapsulate and release therapeutic agents. Additionally, the article explores recent advancements in smart hydrogels with self-healing and antimicrobial properties, providing insights into their potential to revolutionize emergency care and increase survival rates in both civilian and military applications. Through a critical evaluation of current clinical trials and practical deployments, this review highlights both the successes and the challenges faced in integrating hydrogels into emergency medical protocols, providing a roadmap for future research and development in this dynamic field.

Prevalence and outcomes of hypocalcemia on ED arrival in traumatic patients before blood transfusions: a systematic review and meta-analysis

BACKGROUND

Hypocalcemia represents a critical physiological disturbance in trauma-related hemorrhagic shock patients. Nonetheless, the prevalence and effects of hypocalcemia remain uncertain. This study aims to explore the prevalence of hypocalcemia before blood transfusions and its related mortality in adult patients with major traumatic injuries.

METHOD

We conducted a systematic search through databases, including PubMed, EMBASE, Scopus, and Web of Science, from their inception until June 30, 2024. Patients with major traumatic injuries whose serum calcium was measured upon arrival at the emergency department (ED) were included. We excluded those with prior blood transfusions, pre-clinical studies, review articles, and studies without a control group. Meta-analysis using a random-effect model was performed. Heterogeneity was evaluated using Cochrane Q and I² statistics. The study's risk of bias was assessed using the Joanna Briggs Institute's critical appraisal checklist. Publication bias was assessed using Egger's test and contour funnel plot visualization.

RESULTS

Of the total, 1,984 abstracts were screened, leading to 15 studies in this review and meta-analysis. The overall prevalence of hypocalcemia upon ED arrival was 56% (95% CI 37%-74%), with high heterogeneity (I2 99.8%) observed. Hypocalcemia patients also had higher mortality rates than normocalcemia patients (OR 2.44, 95% CI 1.76-3.40).

CONCLUSION

Hypocalcemia on ED arrival is common among adult trauma patients, who also exhibit a notably high mortality rate within this demographic. We recommend the monitoring of ionized calcium levels in traumatic adult patients. Furthermore, systematically designed studies examining the optimal thresholds, treatment protocols, and outcomes should be prioritized as the focal point of research.

TRIAL REGISTRATION

CRD42024549054 ( http://www.crd.york.ac.uk/PROSPERO ).

Effective utilisation of rapid infusion catheters in perioperative care: a narrative review

The Rapid Infusion Catheter (RIC) has transformed intravenous (i.v.) access, allowing for rapid fluid delivery peripherally. It may negate the need for a central vein sheath to be placed. This review explores the clinical utility of RICs while addressing technical considerations and potential risks. The RIC is a large-bore i. v. sheath available in two sizes. Its maximal flow rate is 1200 ml min-1, making it advantageous in significant blood loss scenarios such as trauma and major surgeries. Insertion involves the Seldinger technique. Monitoring and maintaining the RIC is crucial to detect and address immediate complications such as occlusions, infiltration, phlebitis, and extravasation of infusate. Although the related complications share similarities with those of other peripheral i. v. cannulae, they have a lower risk of occlusion and accidental displacement. Catheter removal should be considered once the patient is stable or alternative access is available to avoid infectious complications. Removal of the RIC needs to be performed by those educated in RIC management. Maximal flow rate is an essential factor in assessing the performance of i. v. cannulae, and studies have shown that RICs outperform other peripheral and central catheters in this regard. In conclusion, RIC offers advantages over large-bore central venous access for large-volume rapid infusions, including ease of insertion and reduced severe complications. The RIC demonstrates lower thrombosis rates and a different complication profile than peripherally inserted central catheters. Understanding the characteristics and applications of RICs can help healthcare professionals make informed decisions about their use in various medical scenarios.

Transfusion biomaterials for hemostasis

Bleeding is a leading cause of trauma deaths and surgical complications. Excessive bleeding has traditionally been treated with the transfusion of donated blood. However, the complicated logistics of sourcing and storing donated blood increases the cost and reduces the accessibility of treatment, particularly as rates of blood donation decline. Advances in biomaterials for targeted drug delivery have presented the opportunity for alternative synthetic injectable hemostats. Among these leading technologies are lipid and polymeric particles and polymer platforms that bind to ligands present at wound sites and amplify hemostatic pathways. As leading hemostatic biomaterials advance toward clinical application, we review current preclinical research models and findings as well as future research directions for next-generation biomaterial injectable hemostatic technologies.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy.

METHODS

The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence.

RESULTS

A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients' perspectives are discussed.

CONCLUSION

The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma.

Impact of the Good Samaritan Law on bystander intervention willingness and perceived legal risks in India

BACKGROUND

Road traffic crashes (RTCs) are a global health burden, particularly in India, where response times for first responders can be prolonged. Prior to enactment of a Good Samaritan Law (GSL) in 2016, involved bystanders could face criminal and financial liability for assisting at an RTC site. This study evaluates the impact of GSL on bystander RTC attitudes, awareness, and experiences in India, comparing outcomes pre- and post-GSL implementation across metropolitan cities (MCs) and nonmetropolitan cities (NMCs). We hypothesized that GSL would lead to increased bystander willingness to assist the RTC victim.

METHODS

This retrospective, cross-sectional, observational study analyzed data from two national surveys conducted in 2013 (pre-GSL, n = 1,027) and 2018 (post-GSL, n = 3,667) across 7 and 11 Indian cities, respectively. Difference-in-difference analysis, propensity score matching, and regression models were used to assess changes in willingness to assist RTC victims, awareness of GSL, legal and financial fears, and awareness of GSL.

RESULTS

Post-GSL implementation saw an increase in willingness to assist RTC victims (Δ = +65.4%, p < 0.001) and substantial decreases in fear regarding legal (Δ = -81%, p < 0.001) and financial consequences (Δ = -75.8%, p < 0.001) of rendering assistance. GSL awareness was higher in NMCs (n = 2,215, 31.2%) compared with MCs (n = 838, 9.25%) among general citizens ( p < 0.001). Males showed higher willingness to assist RTC victims ( p < 0.01), whereas individuals with postgraduate education demonstrated increased awareness of GSL ( p < 0.01).

CONCLUSION

The implementation of GSL in India has transformed bystander intervention in RTCs, increasing the reported likelihood of assistance and substantially reducing legal and financial concerns. This shift demonstrates GSL's potential to improve outcomes for RTC victims. However, disparities in awareness between MCs and NMCs, as well as sex- and education-based differences, highlight the need for targeted educational campaigns. Future initiatives should focus on improving application of the law and strengthening the entire trauma chain of survival.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Predicting the future caretakers of traumatic vascular injury management via operative exposure among surgical trainees

BACKGROUND

The management of vascular trauma requires specialized training and expertise. Although traumatic vascular injury is treated currently by both vascular and trauma surgeons in modern practice, it remains unclear who will inherit the role of managing vascular trauma in the coming decades. In this study, we examined disparities in operative experience in vascular trauma among surgical trainees across different surgical specialties.

METHODS

Accreditation Council for Graduate Medical Education national operative log reports were collected for graduating vascular surgery residents (VSRs), vascular surgery fellows (VSFs), and general surgery residents (GSRs) from 2012 to 2022. Total operative volume for traumatic vascular injury was examined, as were the five major contributing operative domains (neck, thoracic, abdominal, peripheral, and fasciotomy).

RESULTS

A total of 22,052 GSRs, 334 VSRs, and 1672 VSFs graduated over the 10-year study period. VSR had the highest vascular trauma case volume (24.9 ± 3.9 cases/5 years), followed by VSF (22.1 ± 1.5 cases/2 years) then GSR (2.4 ± 0.3 cases/5 years; P < .001). Thoracic vessel exploration/repair (0.7 cases vs 0.6 cases vs 0.0 cases), abdominal vessel exploration/repair (1.0 cases vs 0.9 cases vs 0.0 cases), neck vessel exploration/repair (4.0 cases vs 3.4 cases vs 0.2 cases), peripheral vessel exploration/repair (12.1 cases vs 9.5 cases vs 1.1 cases), and lower extremity fasciotomy for trauma (7.2 cases vs 7.6 cases vs 1.1 cases) were most frequent among the VSR and VSF groups (P < .001 each). On linear regression analysis, both VSF (+0.5 cases/y; R2 = 0.81; P < .001) and GSR (+0.1 cases/y; R2 = 0.75; P = .001) groups experienced a growth in vascular trauma volume. Contrariwise, vascular trauma volume did not change among graduating VSRs (R2 = 0.13; P = .31).

CONCLUSIONS

Dedicated vascular surgical training provides the highest operative exposure to civilian vascular trauma in the United States.

Diagnosis of traumatic liver injury on computed tomography using machine learning algorithms and radiomics features: The role of artificial intelligence for rapid diagnosis in emergency rooms

Background

The initial assessment of trauma is a time-consuming and challenging task. The purpose of this research is to examine the diagnostic effectiveness and usefulness of machine learning models paired with radiomics features to identify blunt traumatic liver injury in abdominal computed tomography (CT) images.

Materials and Methods

In this study, 600 CT scan images of people with mild and severe liver damage due to trauma and healthy people were collected from the Kaggle dataset. The axial images were segmented by an experienced radiologist, and radiomics features were extracted from each region of interest. Initially, 30 machine learning models were implemented, and finally, three machine learning models were selected including Light Gradient-Boosting Machine (LGBM), Ridge Classifier, and Extreme Gradient Boosting (XGBoost), and their performance was examined in more detail.

Results

The two criteria of precision and specificity of LGBM and XGBoost models in diagnosing mild liver injury were calculated to be 100%. Only 6.00% of cases were misdiagnosed by the LGBM model. The LGBM model achieved 100% sensitivity and 99.00% accuracy in diagnosing severe liver injury. The area under the receiver operating characteristic curve value and precision of this model were also calculated to be 99.00% and 98.00%, respectively.

Conclusion

The artificial intelligence models used in this study have great potential to improve patient care by assisting radiologists and other physicians in diagnosing and staging trauma-related liver injuries. These models can help prioritize positive studies, allow more rapid evaluation, and identify more severe injuries that may require immediate intervention.

Are crystalloid-based fluid expansion strategies still relevant in the first hours of trauma induced hemorrhagic shock?

BACKGROUND

Crystalloid-based fluid resuscitation has long been a cornerstone in the initial management of trauma-induced hemorrhagic shock. However, its benefit is increasingly questioned as it is suspected to increase bleeding and worsen coagulopathy. The emergence of alternative strategies like permissive hypotension and vasopressor use lead to a shift in early trauma care practices. Critical appraisal of current evidence is necessary to guide clinicians and outline research perspectives.

MAIN TEXT

Current guidelines for managing trauma-induced hemorrhagic shock suggest titrating fluids and using vasopressors to achieve minimal blood pressure targets until hemorrhage is controlled. In case of traumatic brain injury with severe hemorrhage, blood pressure target increases. The scientific literature supporting these recommendations is limited, and several aspects remain the subject of ongoing scientific debate. The aim of this review is to evaluate the existing evidence on low-volume fluid resuscitation during the first hours of trauma management, with an emphasis on its integration with permissive hypotension, vasopressor use and cerebral perfusion pressure in traumatic brain injury. The review also highlights the limitations of current guidelines, particularly the lack of robust evidence supporting specific type of fluid, volumes and administration protocols tailored to specific trauma scenarios and populations. Emerging technologies such as point-of-care diagnostics, integrated monitoring systems, and machine learning hold promise for enhancing clinical decision-making in trauma care. These innovations could play a crucial role, ultimately helping clinicians address critical unanswered questions in trauma management and improve patient survival.

CONCLUSIONS

Crystalloid-based resuscitation remains relevant in early trauma care, but its application must be reassessed considering recent evidence and evolving practices. Further research is essential to refine fluid resuscitation guidelines, particularly in defining safe fluid volumes and the role of vasopressors. The integration of advanced monitoring technologies may offer new opportunities to optimize trauma care and improve outcomes.

Navigating Hemorrhagic Shock: Biomarkers, Therapies, and Challenges in Clinical Care

Hemorrhagic shock remains a leading cause of preventable death worldwide, with mortality patterns varying significantly based on injury mechanisms and severity. This comprehensive review examines the complex pathophysiology of hemorrhagic shock, focusing on the temporal evolution of inflammatory responses, biomarker utility, and evidence-based therapeutic interventions. The inflammatory cascade progresses through distinct phases, beginning with tissue injury and endothelial activation, followed by a systemic inflammatory response that can transition to devastating immunosuppression. Recent advances have revealed pattern-specific responses between penetrating and blunt trauma, necessitating tailored therapeutic approaches. While damage control resuscitation principles and balanced blood product administration have improved outcomes, many molecular targeted therapies remain investigational. Current evidence supports early hemorrhage control, appropriate blood product ratios, and time-sensitive interventions like tranexamic acid administration. However, challenges persist in biomarker validation, therapeutic timing, and implementation of personalized treatment strategies. Future directions include developing precision medicine approaches, real-time monitoring systems, and novel therapeutic modalities while addressing practical implementation barriers across different healthcare settings. Success in hemorrhagic shock management increasingly depends on integrating multiple interventions across different time points while maintaining focus on patient-centered outcomes.

Advancing microfluidic point-of-care platelet function tests: opportunities and challenges from bench to market

Platelets are critical for blood clotting, with shear-induced platelet aggregation (SIPA) playing a key role in hemostasis and the prevention of excessive bleeding. SIPA function potentially leads to life-threatening diseases such as hemorrhage and myocardial infarction, which are leading causes of death globally. Point-of-care platelet function tests (POC PFTs) are developed to assess platelet dysfunction and distinguish between normal and abnormal platelet activity. Recent advances in microfluidic technology have been integrated into POC PFTs, showing promise for delivering more accurate, rapid, and differentiated results using minimal blood sample volumes, enabling more informed treatment decisions. However, current POC PFTs fall short of replicating high-shear thrombotic conditions in vitro, resulting in limited clinical SIPA diagnosis and actionable insights. In this review, we explore the current landscape of POC PFT technology, key challenges, and future opportunities. We highlight the importance of device design and scalable manufacturing to fully realize the potential of microfluidic POC PFTs and facilitate their widespread adoption in clinical practice, ultimately improving patient outcomes.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Delta shock index predicts injury severity, interventions, and outcomes in trauma patients: A 10-year retrospective observational study

BACKGROUND

Most trauma occurs among young male subjects in Qatar. We examined the predictive values of the delta shock index (DSI), defined as the change in the shock index (SI) value from the scene to the initial reading in the emergency unit (i.e., subtracting the calculated SI at admission from SI at the scene), at a Level 1 trauma center.

AIM

To explore whether high DSI is associated with severe injuries, more interventions, and worse outcomes [i.e., blood transfusion, exploratory laparotomy, ventilator-associated pneumonia, hospital length of stay (HLOS), and in-hospital mortality] in trauma patients.

METHODS

A retrospective analysis was conducted after data were extracted from the National Trauma Registry between 2011 and 2021. Patients were grouped based on DSI as low (≤ 0.1) or high (> 0.1). Data were analyzed and compared using χ 2 and Student's t-tests. Correlations between DSI and injury severity score (ISS), revised trauma score (RTS), abbreviated injury scale (AIS), Glasgow coma scale (GCS), trauma score-ISS (TRISS), HLOS, and number of transfused blood units (NTBU), were assessed using correlation coefficient analysis. The diagnostic testing accuracy for predicting mortality was determined using the validity measures of the DSI. Logistic regression analysis was performed to identify predictors of mortality.

RESULTS

This analysis included 13212 patients with a mean age of 33 ± 14 years, and 24% had a high DSI. Males accounted for 91% of the study population. The trauma activation level was higher in patients with a high DSI (38% vs 15%, P = 0.001). DSI correlated with RTS (r = -0.30), TRISS (r = -0.30), NTBU (r = 0.20), GCS (r = -0.24), ISS (r = 0.22), and HLOS (r = 0.14) (P = 0.001 for all). High DSI was associated with significantly higher rates of intubation, laparotomy, ventilator-associated pneumonia, massive transfusion activation, and mortality than low DSI. For mortality prediction, a high DSI had better specificity, negative predictive value, and negative likelihood ratio (77%, 99%, and 0.49%, respectively). After adjusting for age, emergency medical services time, GCS score, and ISS, multivariable regression analysis showed that DSI was an independent predictor of mortality (odds ratio = 1.9; 95% confidence interval: 1.35-2.76).

CONCLUSION

In addition to sex-biased observations, almost one-quarter of the study cohort had a higher DSI and were mostly young. High DSI correlated significantly with the other injury severity scores, which require more time and imaging to be ready to use. Therefore, DSI is a practical, simple bedside tool for triaging and prognosis in young patients with trauma.

Resuscitation of adult shocked trauma patients using major haemorrhage protocol guided by viscoelastic haemostatic assays versus formulaic approach

BACKGROUND

The resuscitation of trauma patients with critical bleeding may follow a formulaic approach using high ratios of blood components or a viscoelastic haemostatic assay (VHA) guided approach. The aim of this study was to compare the two strategies for resuscitation of shocked trauma patients.

METHODS

This was a registry-based cohort study including shocked trauma patients from two trauma centres-one practising a formulaic approach, with VHA unavailable during trauma resuscitation and the other practicing a VHA-guided resuscitation strategy. The primary outcome was the total units of blood components transfused in 24 h after adjusting for differences in baseline characteristics and time to death.

RESULTS

Between 01 Jan 2020 and 31 Dec 2022, 152 eligible patients were categorised to the formulaic group and 40 to the VHA group. Prehospital times were longer in the formulaic group (2.0 vs. 1.4 h), and more patients in the VHA group (38% vs. 17%) were transfused prehospital blood components. Formulaic resuscitation was associated with significantly more blood components transfused (adjusted incidence rate ratio 1.5; 95%CI: 1.4-1.7, p < 0.001). Using a formulaic approach, patients were administered more red blood cells, plasma and platelets, but fewer cryoprecipitate. There was no significant association of the formulaic approach with in-hospital mortality (adjusted odds ratio 2.4; 95%CI: 0.7-8.0, p = 0.17).

CONCLUSIONS

Given the cost and potential adverse effects of blood component transfusions, VHA-guided transfusion strategies present an attractive option, particularly among centres managing high volumes of shocked patients. Further trials, enrolling the population most likely to benefit from precision transfusion strategies, are indicated.

2024 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

This is the eighth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recent published resuscitation evidence reviewed by the International Liaison Committee on Resuscitation task force science experts. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research.

Machine Learning Models for Tracking Blood Loss and Resuscitation in a Hemorrhagic Shock Swine Injury Model

Hemorrhage leading to life-threatening shock is a common and critical problem in both civilian and military medicine. Due to complex physiological compensatory mechanisms, traditional vital signs may fail to detect patients' impending hemorrhagic shock in a timely manner when life-saving interventions are still viable. To address this shortcoming of traditional vital signs in detecting hemorrhagic shock, we have attempted to identify metrics that can predict blood loss. We have previously combined feature extraction and machine learning methodologies applied to arterial waveform analysis to develop advanced metrics that have enabled the early and accurate detection of impending shock in a canine model of hemorrhage, including metrics that estimate blood loss such as the Blood Loss Volume Metric, the Percent Estimated Blood Loss metric, and the Hemorrhage Area metric. Importantly, these metrics were able to identify impending shock well before traditional vital signs, such as blood pressure, were altered enough to identify shock. Here, we apply these advanced metrics developed using data from a canine model to data collected from a swine model of controlled hemorrhage as an interim step towards showing their relevance to human medicine. Based on the performance of these advanced metrics, we conclude that the framework for developing these metrics in the previous canine model remains applicable when applied to a swine model and results in accurate performance in these advanced metrics. The success of these advanced metrics in swine, which share physiological similarities to humans, shows promise in developing advanced blood loss metrics for humans, which would result in increased positive casualty outcomes due to hemorrhage in civilian and military medicine.

Modulating Coagulation via Bioinspired Mesoporous Calcium-Decorated Silica Nanoparticles for Efficient Fibrin Clot Formation

Blood clotting is vital for preventing bleeding after an injury. Hemostasis is a complex cascade involving numerous plasma proteins. Uncontrolled bleeding leads to mortality. The presence of Ca (calcium) activates and promotes the different phases in the coagulation cascade. Even nonbiological surfaces such as silicates may activate coagulation factor XII (FXII). This causes the clotting of the blood. The exceptional hemostatic ability of the mesoporous calcium-decorated silica nanoparticles (MCSNs) is achieved by stimulating the factors needed to form fibrin mesh, a durable clot, thereby establishing hemostasis. This may be used as a hemostatic agent during an accident surgical procedure and other bleeding-related trauma conditions. This study investigates the mechanistic activation of the coagulation cascade by MCSN through blood coagulation index, clotting time, and coagulation activation studies like PT and aPTT. Our finding demonstrates that MCSN induces platelet adhesion and RBC aggregation and activates thrombin generation through distinct pathways.

Survival of the fastest? A descriptive analysis of severely injured trauma patients primarily admitted or secondarily transferred to major trauma centers in a Danish inclusive trauma system

BACKGROUND

Trauma systems are crucial for enhancing survival and quality of life for trauma patients. Understanding trauma triage and patient outcomes is essential for optimizing resource allocation and trauma care.

AIMS

The aim was to explore prehospital trauma triage in Region Zealand, Denmark. Specifically, characteristics for patients who were either primarily admitted or secondarily transferred to major trauma centers were described.

METHODS

A retrospective descriptive study of severely injured trauma patients was conducted from January 2017 to December 2021.

RESULTS

The study comprised 744 patients including 55.6% primary and 44.4% secondary patients. Overall, men accounted for 70.2% of patients, and 66.1% were aged 18-65 years. The secondary patients included more women-34.2% versus 26.3% and a higher proportion of Injury Severity Score of ≥ 15-59.6% versus 47.8%, compared to primary patients. 30-day survival was higher for secondary patients-92.7% versus 87%. Medical dispatchers assessed urgency as Emergency level A for 98.1% of primary patients and 86.3% for secondary patients. Physician-staffed prehospital units attended primary patients first more frequently-17.1% versus 3.5%. Response times were similar, but time at scene was longer for primary patients whereas time from injury to arrival at a major trauma center was longer for secondary patients.

CONCLUSIONS

Secondary trauma patients had higher Injury Severity Scores and better survival rates. They were considered less urgent by medical dispatchers and less frequently assessed by physician-staffed units. Prospective quality data are needed for further investigation of optimal triage and continuous quality improvement in trauma care.

International facets of the 'chain of survival' for out-of-hospital and in-hospital cardiac arrest - A scoping review

Background

The "chain of survival" was first systematically addressed in 1991, and its sequence still forms the cornerstone of current resuscitation guidelines. The term "chain of survival" is widely used around the world in literature, education, and awareness campaigns, but growing heterogeneity in the components of the chain has led to confusion. It is unclear which of these emerging chains is most suitable, or if adaptations are needed in particular contexts to depict key actions of resuscitation in the 21st century. This scoping review provides an overview of the variety of chains of survival described.

Objectives

To identify published facets of the chain of survival, to assess views and strategies about adapting the chain, and to identify reports on how the chain of survival affects teaching, implementation, or patient outcomes.

Methods eligibility criteria and sources of evidence

A scoping review as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) was conducted. MEDLINE(R) ALL (Ovid), Embase (Ovid), APA PsycINFO (Ovid), CINAHL (Ebscohost), ERIC (Ebscohost), Web of Science (Clarivate), Scopus (Elsevier), and Cochrane Library (Wiley Online) were searched. All publications in all languages describing chains of survival were eligible, without time restrictions. Due to the heterogeneity and publication types of the relevant studies, we did not pursue a systematic review or meta-analysis.

Results

A primary search yielded 1713 studies and after screening we included 43 publications. Modified versions of the chain of survival for specific contexts were found (e.g., in-hospital cardiac arrest or paediatric resuscitation). There were also numerous versions with minor adaptations of the existing chain. Three publications suggested an impact of the use of the chain of survival on patient outcomes. No educational or implementation outcomes were reported.

Conclusion

There is a vast heterogeneity of chain of survival concepts published. Future research is warranted, especially into the concept's importance concerning educational, implementation, and clinical outcomes.

Enhancing Trauma Care: A Machine Learning Approach with XGBoost for Predicting Urgent Hemorrhage Interventions Using NTDB Data

OBJECTIVE

Trauma is a leading cause of death worldwide, with many incidents resulting in hemorrhage before the patient reaches the hospital. Despite advances in trauma care, the majority of deaths occur within the first three hours of hospital admission, offering a very limited window for effective intervention. Unfortunately, a significant increase in mortality from hemorrhagic trauma is primarily due to delays in hemorrhage control. Therefore, we propose a machine learning model to predict the need for urgent hemorrhage intervention.

METHODS

This study developed and validated an XGBoost-based machine learning model using data from the National Trauma Data Bank (NTDB) from 2017 to 2019. It focuses on demographic and clinical data from the initial hours following trauma for model training and validation, aiming to predict whether trauma patients require urgent hemorrhage intervention.

RESULTS

The XGBoost model demonstrated superior performance across multiple datasets, achieving an AUROC of 0.872 on the training set, 0.869 on the internal validation set, and 0.875 on the external validation set. The model also showed high sensitivity (77.8% on the external validation set) and specificity (82.1% on the external validation set), with an accuracy exceeding 81% across all datasets, highlighting its high reliability for clinical applications.

CONCLUSIONS

Our study shows that the XGBoost model effectively predicts urgent hemorrhage interventions using data from the National Trauma Data Bank (NTDB). It outperforms other machine learning algorithms in accuracy and robustness across various datasets. These results highlight machine learning's potential to improve emergency responses and decision-making in trauma care.

Predictive parameters for early detection of clinically relevant abdominal trauma in multiple-injury or polytraumatised patients: a retrospective analysis

Diagnosis of relevant organ injury after blunt abdominal injury (AI) in multiple-injury/polytraumatised patients is challenging. AI can be distinguished between injuries of parenchymatous organs (POI) of the upper abdomen (liver, spleen) and bowel and mesenteric injuries (BMI). Still, such injuries may be associated with delays in diagnosis and treatment. The present study aimed to verify laboratory parameters, imaging diagnostics, physical examination and related injuries to predict intraabdominal injuries. This retrospective, single-centre study includes data from multiple-injury/polytraumatised patients between 2005 and 2017. Two main groups were defined with relevant abdominal injury (AI+) and without abdominal injury (AI-). The AI+ group was divided into three subgroups: BMI+, BMI+/POI+, and POI+. Groups were compared in a univariate analysis for significant differences. Logistic regression analysis was used to determine predictors for AI+, BMI+ and POI+. 26.3% (271 of 1032) of the included patients had an abdominal injury. Subgroups were composed of 4.7% (49 of 1032) BMI+, 4.7% (48 of 1032) BMI+/POI+ and 16.8% (174 of 1032) POI+. Pathological abdominal signs had a sensitivity of 48.7% and a specificity of 92.4% for AI+. Transaminases were significantly higher in cases of AI+. Pathological computed tomography (CT) (free fluid, parenchymal damage, Bowel Injury Prediction Score (BIPS), CT Grade > 4) was summarised and had a sensitivity of 94.8%, a specificity of 98%, positive predictive value (PPV) of 94.5% and, negative predictive value (NPV) of 98.2% for AI+. The detected predictors for AI+ were pathological abdominal findings (odds ratio (OR) 3.93), pathological multi-slice computed tomography (MSCT) (OR 668.9), alanine (ALAT) ≥ 1.23 µmol/ls (OR 2.35) and associated long bone fractures (OR 3.82). Pathological abdominal signs, pathological MSCT and lactate (LAC) levels ≥ 1.94 mmol/l could be calculated as significant risk factors for BMI+. For POI+ pathological abdominal MSCT, ASAT ≥ 1.73 µmol/ls and concomitant thoracic injuries had significant relevance. The study presents reliable risk factors for abdominal injury and its sub-entities. The predictors can be explained by the anatomy of the trunk and existing studies. Elevated transaminases predicted abdominal injury (AI+) and, specifically, the POI+. The pathological MSCT was the most reliable predictive parameter. However, it was essential to include further relevant parameters.

Microbubble Contrast Agents Improve Detection of Active Hemorrhage

Assessment of trauma-induced hemorrhage with ultrasound is particularly challenging outside of the clinic, where its detection is crucial. The current clinical standard for hematoma detection - the focused assessment with sonography of trauma (FAST) exam - does not aim to detect ongoing blood loss, and thus is unable to detect injuries of increasing severity. To enhance detection of active bleeding, we propose the use of ultrasound contrast agents (UCAs), together with a novel flow phantom and contrast-sensitive processing techniques, to facilitate efficient, practical characterization of internal bleeding. Within a the custom phantom, UCAs and processing techniques enabled a significant enhancement of the hemorrhage visualization (mean increase in generalized contrast-to-noise ratio of 17%) compared to the contrast-free case over a range of flow rates up to 40 ml/min. Moreover, we have shown that the use of UCAs improves the probability of detection: the area under the receiver operating characteristic curve for a flow rate of 40 ml/min was 0.99, compared to 0.72 without contrast. We also demonstrate how additional processing of the spatial and temporal information further localizes the bleeding site. UCAs also enhanced Doppler signals over the non-contrast case. These results show that specialized nonlinear processing (NLP) pipelines together with UCAs may offer an efficient means to improve substantially the detection of slower hemorrhages and increase survival rates for trauma-induced injury in pre-hospital settings.

Characteristics of traumatic major haemorrhage in a tertiary trauma center

BACKGROUND

Major traumatic haemorrhage is potentially preventable with rapid haemorrhage control and improved resuscitation techniques. Although advances in prehospital trauma management, haemorrhage is still associated with high mortality. The aim of this study was to use a recent pragmatic transfusion-based definition of major bleeding to characterize patients at risk of major bleeding and associated outcomes in this cohort after trauma.

METHODS

This was a retrospective cohort study including all trauma patients (n = 7020) admitted to a tertiary trauma center from January 2015 to June 2020. The major bleeding cohort (n = 145) was defined as transfusion of 4 units of any blood components (red blood cells, plasma, or platelets) within 2 h of injury. Univariate and multivariable logistic regression analyses were performed to identify risk factors for 24-hour and 30-day mortality post trauma admission.

RESULTS

In the major bleeding cohort (n = 145; 145/7020, 2.1% of the trauma population), there were 77% men (n = 112) and 23% women (n = 33), median age 39 years [IQR 26-53] and median Injury Severity Score (ISS) was 22 [IQR 13-34]. Blunt trauma dominated over penetrating trauma (58% vs. 42%) where high-energy fall was the most common blunt mechanism and knife injury was the most common penetrating mechanism. The major bleeding cohort was younger (OR 0.99; 95% CI 0.98 to 0.998, P = 0.012), less female gender (OR 0.66; 95% CI 0.45 to 0.98, P = 0.04), and had more penetrating trauma (OR 4.54; 95% CI 3.24 to 6.36, P = 0.001) than the rest of the trauma cohort. A prehospital (OR 2.39; 95% CI 1.34 to 4.28; P = 0.003) and emergency department (ED) (OR 6.91; 95% CI 4.49 to 10.66, P = 0.001) systolic blood pressure < 90 mmHg was associated with the major bleeding cohort as well as ED blood gas base excess < -3 (OR 7.72; 95% CI 5.37 to 11.11; P < 0.001) and INR > 1.2 (OR 3.09; 95% CI 2.16 to 4.43; P = 0.001). Emergency damage control laparotomy was performed more frequently in the major bleeding cohort (21.4% [n = 31] vs. 1.5% [n = 106]; OR 3.90; 95% CI 2.50 to 6.08; P < 0.001). There was no difference in transportation time from alarm to hospital arrival between the major bleeding cohort and the rest of the trauma cohort (47 [IQR 38;59] vs. 49 [IQR 40;62] minutes; P = 0.17). However, the major bleeding cohort had a shorter time from ED to first emergency procedure (71.5 [IQR 10.0;129.0] vs. 109.00 [IQR 54.0; 259.0] minutes, P < 0.001). In the major bleeding cohort, patients with penetrating trauma, compared to blunt trauma, had a shorter alarm to hospital arrival time (44.0 [IQR 35.5;54.0] vs. 50.0 [IQR 41.5;61.0], P = 0.013). The 24-hour mortality in the major bleeding cohort was 6.9% (10/145). All fatalities were due to blunt trauma; 40% (4/10) high energy fall, 20% (2/10) motor vehicle accident, 10% (1/10) motorcycle accident, 10% (1/10) traffic pedestrian, 10% (1/10) traffic other, and 10% (1/10) struck/hit by blunt object. In the logistic regression model, prehospital cardiac arrest (OR 83.4; 95% CI 3.37 to 2063; P = 0.007) and transportation time (OR 0.95, 95% CI 0.91 to 0.99, P = 0.02) were associated with 24-hour mortality.

RESULTS

Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control. The major bleeding trauma cohort is a small part of the entire trauma population, and is characterized of being younger, male gender, higher ISS, and exposed to more penetrating trauma. Early identification of patients at high risk of major bleeding is challenging but essential for rapid definitive haemorrhage control.

Predictors for anaemia, blood transfusion and outcome in plastic surgery patients

OBJECTIVE

In patients undergoing plastic surgery, to identify specific risk factors for anaemia and use of blood products, and assess their impact on patient outcome.

METHOD

For this retrospective study, data were analysed from patients who attended the Plastic Surgery Department at our hospital over a three-year period (2018 to 2020). Adult patients who presented with traumatic injuries, oncologic patients who underwent reconstructive procedures, and patients with soft tissue infections (STIs) who required plastic surgery for tissue coverage were included. Demographic and injury data, hospital admission characteristics, surgical procedures, laboratory test results, transfusion events, and in-hospital complications were extracted from patient records.

RESULTS

Of the 350 patients included in the study, 228 (65%) presented with trauma, 76 (22%) underwent reconstructive surgery for cancers and 46 (13%) had STIs. In total, 175 (50%) patients developed anaemia, and 37 (11%) received blood transfusions; these were 20 (54%), 5 (14%), and 12 (32%) patients in the trauma, cancer and STI groups, respectively. Associated comorbidities and upper and lower limb surgery were the most significant risk factors for anaemia, while the number of surgeries and NSTIs were identified as risk factors for blood transfusions. Direct wound closure was consistently a protective factor for both anaemia and blood transfusions. Blood transfusions were independently associated with a high risk of sepsis, wound complications, and prolonged hospital stay.

CONCLUSION

While transfusions are necessary and even lifesaving in surgical patients, blood is a finite resource and its use may negatively impact patient outcome. Therefore, ongoing research must focus on providing safe and restrictive clinical practices while developing sustainable and accessible alternatives.

Prehospital Blood Transfusion: A Cross-Sectional Study of Prehospital and Retrieval Medicine Services across Australia & Aotearoa-New Zealand

BACKGROUND

The frequency and type of prehospital blood product delivery across Australia and Aotearoa-New Zealand is unknown. This study aims to describe transfusion practice across different services in the two nations, as well as identifying potential barriers to the carriage of blood products.

METHODOLOGY

Prehospital and retrieval medicine services operating teams of doctors, specialist paramedics, and/or flight nurses out of specialty bases across Australia and Aotearoa-New Zealand were sent a standardized questionnaire regarding their base characteristics and their current blood transfusion practice. Bases that only performed inter-hospital transfers or search & rescue operations were excluded. Bases were queried on personnel, equipment, transport times, type and volume of blood products carried, frequency of use, and barriers to implementation for those without prehospital blood transfusion programs.

RESULTS

64 bases were identified and contacted, of which 5 were excluded and 45 of the remaining 59 (76.3%) responded. 62% (28/45) of respondents routinely carry prehospital blood products. 78.6% (22/28) carried packed red blood cells (PRBC) only, 14.3% (4/28) carried both PRBC and plasma, and 1 service (3.6%) carried whole blood. The mean number of units of blood product carried was 3.3 (SD 0.82). 2 bases (7.1%) carried fibrinogen concentrate. All services carried tranexamic acid and calcium. 734 patients received a blood transfusion in 2021, with trauma being the most common indication (552, 75.2%). Base characteristics varied significantly in staffing, vehicle platform and transfer times. The median transfer time from scene to hospital was 65 min (IQR of 40-92). Services without access to prehospital blood products identified multiple barriers to implementation, including training and supply chain.

CONCLUSION

Approximately two-thirds of prehospital services operating advanced teams across Australia and Aotearoa-New Zealand carried blood products and there was wide variation both in the type and number of blood products carried by each base. Multiple barriers to the carriage of blood by all bases were reported, which have implications for service equity. Transfer times are generally long in Australia and Aotearoa-New Zealand, which may impact the generalizability of overseas research performed in prehospital systems with significantly shorter transfer times to services operating in Australia and Aotearoa-New Zealand.

The end of balloons? Our take on the UK-REBOA trial

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used. The recently published UK-REBOA trial aimed to investigate patients suffering haemorrhagic shock and randomized to standard care alone or REBOA as adjunct to standard care and concludes that REBOA may increase the mortality.

MAIN BODY

In this commentary we try to balance the discussion on use of REBOA and address limitations in the UK-REBOA trial that may have influenced the outcome of the study.

CONCLUSION

The situation is complex, and the patients are in extremis. In summary, we do not think this is the end of balloons.

Hospital Resource Planning for Mass Casualty Incidents: Limitations for Coping with Multiple Injured Patients

Using a discrete-event simulation (DES) model, the current disaster plan regarding the allocation of multiple injured patients from a mass casualty incident was evaluated for an acute specialty hospital in Vienna, Austria. With the current resources available, the results showed that the number of severely injured patients currently assigned might have to wait longer than the medically justifiable limit for lifesaving surgery. Furthermore, policy scenarios of increasing staff and/or equipment did not lead to a sufficient improvement of this outcome measure. However, the mean target waiting time for critical treatment of moderately injured patients could be met under all policy scenarios. Using simulation-optimization, an optimal staff-mix could be found for an illustrative policy scenario. In addition, a multiple regression model of simulated staff-mix policy scenarios identified staff categories (number of radiologists and rotation physicians) with the highest impact on waiting time and survival. In the short term, the current hospital disaster plan should consider reducing the number of severely injured patients to be treated. In the long term, we would recommend expanding hospital capacity-in terms of both structural and human resources as well as improving regional disaster planning. Policymakers should also consider the limitations of this study when applying these insights to different areas or circumstances.

National Assessment of Opportunities for Improvement in Preventable Trauma Deaths: A Mixed-Methods Study

Trauma is a significant public health issue worldwide, particularly affecting economically active age groups. Quality management of trauma care at the national level is crucial to improve outcomes of major trauma. In Korea, a biennial nationwide survey on preventable trauma death rate is conducted. Based on the survey results, we analyzed opportunities for improving the trauma treatment process. Expert panels reviewed records of 8282 and 8482 trauma-related deaths in 2017 and 2019, respectively, identifying 258 and 160 cases in each year as preventable deaths. Opportunities for improvement were categorized into prehospital, interhospital, and hospital stages. Hemorrhage was the primary cause of death, followed by sepsis/multiorgan failure and central nervous system injury. Delayed hemostatic procedures and transfusions were common areas for improvement in hospital stage. Interhospital transfers experienced significant delays in arrival time. This study emphasizes the need to enhance trauma care by refining treatment techniques, centralizing patients in specialized facilities, and implementing comprehensive reviews and performance improvements throughout the patient transfer system. The findings offer valuable insights for addressing trauma care improvement from both clinical and systemic perspectives.