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Schwietring J, Wähnert D, Scholl LS, Thies KC. [Prehospital blood transfusion : Opportunities and challenges for the German emergency medical services]. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01463-9. [PMID: 39356309 DOI: 10.1007/s00101-024-01463-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/18/2024] [Indexed: 10/03/2024]
Abstract
BACKGROUND Exsanguination is the leading cause of preventable death in severe trauma. Immediate hemorrhage control and transfusion of blood products are critical to maintain oxygen delivery and address trauma-induced coagulopathy. While prehospital blood product transfusion (PHBT) is established in neighboring countries, the fragmented configuration of Germany's emergency medical service (EMS) infrastructure has delayed the adoption of widespread PHBT programmes. This review aims to provide an updated perspective on the evolution, international practices and research needs of PHBT within the German context. METHODS This narrative review is based on a PubMed search using the search terms "prehospital" and "blood*". From an initial 4738 articles, 333 were directly related to PHBT and were subjected to further detailed examination. The literature, including referenced studies, was categorized into areas such as history, rationale, international practices, and evidence, and analyzed for quality. RESULTS The benefit of early blood transfusion in major trauma has been established since WW1, explaining the efforts to initiate this lifesaving intervention as early as possible in the care pathway, including the prehospital field. Recent randomized trials have faced design and recruitment challenges, reflecting the complexity of the research question. These trials have yielded inconclusive results regarding the survival benefits of PHBT in civilian settings. This scenario raises doubts about the capability of randomized trials to resolve questions concerning survival advantages. Despite these difficulties, there is a discernible trend indicating potential improvements in patient outcomes. In Germany, the incidence of trauma-associated shock stands at 38 per 100,000 individuals per year. It is estimated that between 300 and 1800 patients annually possibly benefit from PHBT. CONCLUSION Prehospital Blood Transfusion appears to be promising but identifying patient groups most likely to benefit as well as the most suitable blood products remain unresolved issues. In Germany PHBT programs are not yet widely established. Paradoxically, this situation, paired with the extensive German Trauma Registry, provides a prime opportunity for comprehensive prospective cohort studies, addressing the balance between PHBT benefits, logistical feasibility, and implementation strategies. Such studies are essential for establishing guidelines and integrating PHBT efficiently into German trauma care protocols.
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Affiliation(s)
- Jens Schwietring
- Ruhr-Universität Bochum, Medizinische Fakultät, Bochum, Deutschland.
- ADAC Luftrettung gGmbH, Hansastr. 19, 80686, München, Deutschland.
| | - Dirk Wähnert
- Universität Bielefeld, Medizinische Fakultät und Universitätsklinikum OWL, Ev. Klinikum Bethel, Universitätsklinik für Unfallchirurgie und Orthopädie, Bielefeld, Deutschland
| | | | - Karl-Christian Thies
- Universität Bielefeld, Medizinische Fakultät und Universitätsklinikum OWL, Ev. Klinikum Bethel, Universitätsklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin, Transfusionsmedizin und Schmerztherapie, Bielefeld, Deutschland
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Schoenfeld DW, Rosen CL, Harris T, Thomas SH. Response to: "Evaluating the efficacy of prehospital transfusion: A critical analysis". Acad Emerg Med 2024. [PMID: 39324382 DOI: 10.1111/acem.15025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 09/05/2024] [Indexed: 09/27/2024]
Affiliation(s)
- David W Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Carlo L Rosen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and 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 and 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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3
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Carenzo L, Calgaro G, Rehn M, Perkins Z, Qasim ZA, Gamberini L, Ter Avest E. Contemporary management of traumatic cardiac arrest and peri-arrest states: a narrative review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:66. [PMID: 39327636 PMCID: PMC11426104 DOI: 10.1186/s44158-024-00197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 08/29/2024] [Indexed: 09/28/2024]
Abstract
Trauma is a leading cause of death and disability worldwide across all age groups, with traumatic cardiac arrest (TCA) presenting a significant economic and societal burden due to the loss of productive life years. Despite TCA's high mortality rate, recent evidence indicates that survival with good and moderate neurological recovery is possible. Successful resuscitation in TCA depends on the immediate and simultaneous treatment of reversible causes according to pre-established algorithms. The HOTT protocol, addressing hypovolaemia, oxygenation (hypoxia), tension pneumothorax, and cardiac tamponade, forms the foundation of TCA management. Advanced interventions, such as resuscitative thoracotomy and resuscitative endovascular balloon occlusion of the aorta (REBOA), further enhance treatment. Contemporary approaches also consider metabolic factors (e.g. hyperkalaemia, calcium imbalances) and hemostatic resuscitation. This narrative review explores the advanced management of TCA and peri-arrest states, discussing the epidemiology and pathophysiology of peri-arrest and TCA. It integrates classic TCA management strategies with the latest evidence and practical applications.
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Affiliation(s)
- Luca Carenzo
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milano, 20089, Italy.
| | - Giulio Calgaro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
| | - Marius Rehn
- Pre-Hospital Division, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Zane Perkins
- Centre for Trauma Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- London's Air Ambulance and Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Zaffer A Qasim
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Ewoud Ter Avest
- London's Air Ambulance and Barts Health NHS Trust, Royal London Hospital, London, UK
- Department of Emergency Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
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Katzenschlager S, Obermaier M, Kaltschmidt N, Bechtold J, Spöttl W, Dietrich M, Weigand MA, Weilbacher F, Popp E. [Focus emergency medicine 2023/2024-Summary of selected studies in emergency medicine]. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01465-7. [PMID: 39317819 DOI: 10.1007/s00101-024-01465-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/02/2024] [Indexed: 09/26/2024]
Affiliation(s)
- S Katzenschlager
- Klinik für Anästhesiologie, Sektion Notfallmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - M Obermaier
- Klinik für Anästhesiologie, Sektion Notfallmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - N Kaltschmidt
- Klinik für Anästhesiologie, Sektion Notfallmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - J Bechtold
- Klinik für Anästhesiologie, Sektion Notfallmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - W Spöttl
- Klinik für Anästhesiologie, Sektion Notfallmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Sektion Notfallmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Sektion Notfallmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - F Weilbacher
- Klinik für Anästhesiologie, Sektion Notfallmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - E Popp
- Klinik für Anästhesiologie, Sektion Notfallmedizin, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Dion PM, von Vopelius-Feldt J, Drennan IR, Nolan B. The future of prehospital whole blood transfusion in Canadian trauma care. CAN J EMERG MED 2024:10.1007/s43678-024-00756-7. [PMID: 39106002 DOI: 10.1007/s43678-024-00756-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 07/26/2024] [Indexed: 08/07/2024]
Affiliation(s)
| | - Johannes von Vopelius-Feldt
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Ornge Air Ambulance and Critical Care Transport, Mississauga, ON, Canada
| | - Ian R Drennan
- Ornge Air Ambulance and Critical Care Transport, Mississauga, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, Institute of Health Policy, Management, Evaluation, University of Toronto, Toronto, Canada
- Department of Emergency Services and Sunnybrook Research Institute, Sunnybrook Health Science Centre, Toronto, Canada
| | - Brodie Nolan
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada.
- Department of Emergency Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Ornge Air Ambulance and Critical Care Transport, Mississauga, ON, Canada.
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Coulthard SL, Kaplan LJ, Cannon JW. What's new in whole blood resuscitation? In the trauma bay and beyond. Curr Opin Crit Care 2024; 30:209-216. [PMID: 38441127 DOI: 10.1097/mcc.0000000000001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
PURPOSE OF REVIEW Transfusion therapy commonly supports patient care during life-threatening injury and critical illness. Herein we examine the recent resurgence of whole blood (WB) resuscitation for patients in hemorrhagic shock following trauma and other causes of severe bleeding. RECENT FINDINGS A growing body of literature supports the use of various forms of WB for hemostatic resuscitation in military and civilian trauma practice. Different types of WB include warm fresh whole blood (FWB) principally used in the military and low titer O cold stored whole blood (LTOWB) used in a variety of military and civilian settings. Incorporating WB initial resuscitation alongside subsequent component therapy reduces aggregate blood product utilization and improves early mortality without adversely impacting intensive care unit length of stay or infection rate. Applications outside the trauma bay include prehospital WB and use in patients with nontraumatic hemorrhagic shock. SUMMARY Whole blood may be transfused as FWB or LTOWB to support a hemostatic approach to hemorrhagic shock management. Although the bulk of WB resuscitation literature has appropriately focused on hemorrhagic shock following injury, extension to other etiologies of severe hemorrhage will benefit from focused inquiry to address cost, efficacy, approach, and patient-centered outcomes.
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Affiliation(s)
- Stacy L Coulthard
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Lewis J Kaplan
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Surgical Critical Care, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Jeremy W Cannon
- Department of Surgery, Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Vulliamy P, Armstrong PC. Platelets in Hemostasis, Thrombosis, and Inflammation After Major Trauma. Arterioscler Thromb Vasc Biol 2024; 44:545-557. [PMID: 38235557 DOI: 10.1161/atvbaha.123.318801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Trauma currently accounts for 10% of the total global burden of disease and over 5 million deaths per year, making it a leading cause of morbidity and mortality worldwide. Although recent advances in early resuscitation have improved early survival from critical injury, the mortality rate in patients with major hemorrhage approaches 50% even in mature trauma systems. A major determinant of clinical outcomes from a major injury is a complex, dynamic hemostatic landscape. Critically injured patients frequently present to the emergency department with an acute traumatic coagulopathy that increases mortality from bleeding, yet, within 48 to 72 hours after injury will switch from a hypocoagulable to a hypercoagulable state with increased risk of venous thromboembolism and multiple organ dysfunction. This review will focus on the role of platelets in these processes. As effectors of hemostasis and thrombosis, they are central to each phase of recovery from injury, and our understanding of postinjury platelet biology has dramatically advanced over the past decade. This review describes our current knowledge of the changes in platelet behavior that occur following major trauma, the mechanisms by which these changes develop, and the implications for clinical outcomes. Importantly, supported by research in other disease settings, this review also reflects the emerging role of thromboinflammation in trauma including cross talk between platelets, innate immune cells, and coagulation. We also address the unresolved questions and significant knowledge gaps that remain, and finally highlight areas that with the further study will help deliver further improvements in trauma care.
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Affiliation(s)
- Paul Vulliamy
- Centre for Trauma Sciences (P.V.), Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Paul C Armstrong
- Centre for Immunobiology (P.C.A.), Blizard Institute, Faculty of Medicine and Dentistry, Queen Mary University of London, United Kingdom
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Antonacci G, Williams A, Smith J, Green L. Study of Whole blood in Frontline Trauma (SWiFT): implementation study protocol. BMJ Open 2024; 14:e078953. [PMID: 38316586 PMCID: PMC11145983 DOI: 10.1136/bmjopen-2023-078953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Uncontrolled bleeding is a major cause of death for patients with major trauma. Current transfusion practices vary, and there is uncertainty about the optimal strategy. Whole blood (WB) transfusion, which contains all components in one bag, is considered potentially advantageous, particularly for resuscitating patients with major bleeding in the prehospital setting. It could potentially improve survival, reduce donor risk and simplify the processes of delivering blood transfusions outside hospitals. However, the evidence supporting the effectiveness and safety of WB compared with the standard separate blood component therapy is limited. A multicentre randomised controlled trial will be conducted, alongside an implementation study, to assess the efficacy, cost-effectiveness and implementation of prehospital WB transfusion in the prehospital environment. The implementation study will focus on evaluating the acceptability and integration of the intervention into clinical settings and on addressing broader contextual factors that may influence its success or failure. METHODS AND ANALYSIS A type 1 effectiveness-implementation hybrid design will be employed. The implementation study will use qualitative methods, encompassing comprehensive interviews and focus groups with operational staff, patients and blood donor representatives. Staff will be purposefully selected to ensure a wide range of perspectives based on their professional background and involvement in the WB pathway. The study design includes: (1) initial assessment of current practice and processes in the WB pathway; (2) qualitative interviews with up to 40 operational staff and (3) five focus groups with staff and donor representatives. Data analysis will be guided by the theoretical lenses of the Normalisation Process Theory and the Theoretical Framework of Acceptability. ETHICS AND DISSEMINATION The study was prospectively registered and approved by the South Central-Oxford C Research Ethics Committee and the Health Research Authority and Health and Care Research Wales. The results will be published in peer-reviewed journals and provided to all relevant stakeholders. TRIAL REGISTRATION NUMBER ISRCTN23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072.
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Affiliation(s)
- Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Allison Williams
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jason Smith
- Department of Emergency, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - Laura Green
- NHS Blood & Transplant and Barts Health NHS Trust, London, UK
- Queen Mary University of London Blizard Institute, London, UK
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