1
|
Gendler S, Gelikas S, Talmy T, Lipsky AM, Avital G, Nadler R, Radomislensky I, Ahimor A, Glassberg E, Mozer Glassberg Y, Almog O, Yazer MH, Benov A. Prehospital Tranexamic Acid Administration in Pediatric Trauma Patients: A Propensity-Matched Analysis of the Israeli Defense Forces Registry. Pediatr Crit Care Med 2023; 24:e236-e243. [PMID: 36752620 DOI: 10.1097/pcc.0000000000003202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVES Tranexamic acid (TXA) administration confers a survival benefit in bleeding trauma patients; however, data regarding its use in pediatric patients are limited. This study evaluates the prehospital treatment with TXA in pediatric trauma patients treated by the Israel Defense Forces Medical Corps (IDF-MC). DESIGN Retrospective, cohort study using the Israel Defense Forces registry, 2011-2021. PATIENTS Pediatric trauma patients less than 18 years old. We excluded patients pronounced dead at the scene. INTERVENTIONS None. SETTING All cases of pediatric trauma in the registry were assessed for treatment with TXA. Propensity score matching was used to assess the association between prehospital TXA administration and mortality. MEASUREMENTS AND MAIN RESULTS Overall, 911 pediatric trauma patients were treated with TXA by the IDF-MC teams; the median (interquartile) age was 10 years (5-15 yr), and 72.8% were male. Seventy patients (7.6%) received TXA, with 52 of 70 (74%) receiving a 1,000 mg dose (range 200-1,000 mg). There were no prehospital adverse events associated with the use of TXA (upper limit of 95% CI for 0/70 is 4.3%). Compared with pediatric patients who did not receive TXA, patients receiving TXA were more likely to suffer from shock (40% vs 10.7%; p < 0.001), sustain more penetrating injuries (72.9% vs 31.7%; p < 0.001), be treated with plasma or crystalloids (62.9% vs 11.4%; p < 0.001), and undergo more lifesaving interventions (24.3% vs 6.2%; p < 0.001). The propensity score matching failed to identify an association between TXA and lesser odds of mortality, although a lack of effect (or even adverse effect) could not be excluded (non-TXA: 7.1% vs TXA: 4.3%, odds ratio = 0.584; 95% CI 0.084-3.143; p = 0.718). CONCLUSIONS Although prehospital TXA administration in the pediatric population is feasible with adverse event rate under 5%, more research is needed to determine the appropriate approach to pediatric hemostatic resuscitation and the role of TXA in this population.
Collapse
Affiliation(s)
- Sami Gendler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Shaul Gelikas
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Tomer Talmy
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Ari M Lipsky
- Department of Emergency Medicine, HaEmek Medical Center, Afula, Israel
| | - Guy Avital
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Roy Nadler
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Irina Radomislensky
- The National Center for Trauma & Emergency Medicine Research, Gertner Institute, Ramat Gan, Israel
| | - Alon Ahimor
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
| | - Elon Glassberg
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- The Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Yael Mozer Glassberg
- Institute of Pediatric Gastroenterology, Nutrition and Liver Diseases, Schneider Children Medical Center of Israel, Petah Tikva, Israel
| | - Ofer Almog
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- The Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
- Department of Pathology, Tel Aviv University, Tel Aviv, Israel
| | - Avi Benov
- Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| |
Collapse
|
2
|
Massive Hemorrhage Protocol. Emerg Med Clin North Am 2023; 41:51-69. [DOI: 10.1016/j.emc.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
3
|
Deeb AP, Hoteit L, Li S, Guyette FX, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Sperry JL, Brown JB. Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage. J Trauma Acute Care Surg 2022; 93:52-58. [PMID: 35393385 PMCID: PMC9233003 DOI: 10.1097/ta.0000000000003620] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage. METHODS We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders. RESULTS A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02). CONCLUSION For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
Collapse
Affiliation(s)
- Andrew-Paul Deeb
- From the Division of Trauma and General Surgery, Department of Surgery (A.-P.D., L.H., S.L., M.D.N., J.L.S., J.B.B.), Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; and Department of Surgery (G.A.V., T.O.K., B.J.), University of Arizona, Tucson, Arizona
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Botteri M, Celi S, Perone G, Prati E, Bera P, Villa GF, Mare C, Sechi GM, Zoli A, Fagoni N. Effectiveness of massive transfusion protocol activation in pre-hospital setting for major trauma. Injury 2022; 53:1581-1586. [PMID: 35000744 DOI: 10.1016/j.injury.2021.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/16/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hemorrhage in major trauma is life-threatening and the activation of the Massive Transfusion Protocol (MTP) was found to reduce the time to transfusion and mortality. The purpose was (i) to verify whether MTP activation identifies patients that require massive transfusions once admitted to the Emergency Department (ED), (ii) to establish whether pre-hospital MTP activation reduces the time to transfusion on arrival at the ED, (iii) to identify the variable that best predicts MTP activation. MATERIALS AND METHODS This is a retrospective, single-center study. The MTP was implemented at the end of 2012; it was activated for major trauma in pre-hospital setting on the basis on established criteria. Pre-hospital MTP activation aimed to make blood products available prior to the patients' arrival at the ED. The blood products are transfused when the patient arrives at the hospital. RESULTS The MTP was activated in pre-hospital setting in 219 patients. On arrival at the hospital, the Trauma Team Leader confirmed MTP activation in 146 (66.7%) patients. Patients with MTP criteria received a higher amount of blood products than the patients without MTP criteria, median 7 (IQR 2-13) units versus 2 (0-6) units, respectively (P < 0.001). At the same time, patients with a Shock Index ≥ 0.9 received more transfusions (5.5 [2-13] units) compared with patients characterized by a lower SI (2 [0-7.25] units, P = 0.009). 146 patients were transfused in the first hour of ED admission. Poisson's multiple regression shows that the SI is the variable that better predicted MTP activation compared to age, gender and the number of injured sites. CONCLUSIONS Pre-hospital MTP activation is useful to identify patients that require an urgent blood transfusion on arrival at the ED. Further analysis should be considered to evaluate the implementation of the Shock Index as a criterion to activate MTP.
Collapse
Affiliation(s)
- Marco Botteri
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy; Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ), Milano, Italy
| | - Simone Celi
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy
| | - Giovanna Perone
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy
| | - Enrica Prati
- Immuno-Haematology and Transfusional Medicine Service (SIMT), ASST Spedali Civili University Hospital, Brescia, Italy
| | - Paola Bera
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy
| | | | - Claudio Mare
- Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ), Milano, Italy
| | | | - Alberto Zoli
- Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ), Milano, Italy
| | - Nazzareno Fagoni
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy; Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ), Milano, Italy; Department of Molecular and Translational Medicine, University of Brescia, Italy.
| |
Collapse
|
5
|
Colomina MJ, Contreras L, Guilabert P, Koo M, Méndez E, Sabate A. Clinical use of tranexamic acid: evidences and controversies. Braz J Anesthesiol 2021; 72:795-812. [PMID: 34626756 DOI: 10.1016/j.bjane.2021.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 08/03/2021] [Accepted: 08/08/2021] [Indexed: 11/26/2022] Open
Abstract
Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.
Collapse
Affiliation(s)
- Maria J Colomina
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain.
| | - Laura Contreras
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Patricia Guilabert
- Universitat Autònoma de Barcelona, Vall d'Hebron University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Maylin Koo
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
| | - Esther Méndez
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain
| | - Antoni Sabate
- Bellvitge University Hospital, Department of Anaesthesia, Critical Care & Pain, Barcelona, Spain; Barcelona University, Barcelona, Spain
| |
Collapse
|
6
|
Maegele M. Prehospital Tranexamic Acid (TXA) in Patients with Traumatic Brain Injury (TBI). Transfus Med Rev 2021; 35:87-90. [PMID: 34598876 DOI: 10.1016/j.tmrv.2021.08.003] [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: 05/06/2021] [Revised: 08/11/2021] [Accepted: 08/28/2021] [Indexed: 10/20/2022]
Abstract
Traumatic brain injury (TBI) remains a significant medical and socioeconomic challenge. The initial injury may be complicated by haemostatic derangements leading to exacerbation of lesions and haemorrhagic progression. The results from the CRASH-3 trial have promoted the implementation of the antifibrinolytic tranexamic acid (TXA) into prehospital Emergency Medical Services (EMS) protocols. Very recently, the efficacy and safety of early out-of-hospital TXA compared to placebo was assessed in patients with moderate or severe TBI in a prospective, multicenter phase II trial, e.g. "The Prehospital TXA for TBI"-trial. Simultaneously, the results from a retrospective analysis of prospectively collected observational data into the Dutch pre-hospital TBI database were published which had assessed whether prehospital administration of TXA may be associated with mortality and functional outcomes in patients with severe TBI. Both studies are reviewed against their limitations and windows of opportunity are highlighted.
Collapse
Affiliation(s)
- Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany; Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany; Treatment Center for Traumatic Injuries, 3rd Affiliated Hospital Southern Medical University (SMU), Guangdong Province, People's Republic, China.
| |
Collapse
|
7
|
Lima LPDST, Santos PRS, Martins HJ, Rodrigues DADS, Silva LM, Libardi MBO, Azevedo NAM. Use of Tranexamic Acid in Traumatic Resuscitation in a Prehospital Setting: A Case Report. Air Med J 2021; 40:359-362. [PMID: 34535245 DOI: 10.1016/j.amj.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/28/2021] [Accepted: 05/27/2021] [Indexed: 10/21/2022]
Abstract
This study describes the use of tranexamic acid associated with other measures in the initial approach to contain bleeding in a situation of hemorrhagic shock in a trauma patient. The case describes the care of a young man with multiple thorax punctures by a melee weapon, quickly progressing to a condition of severe shock, in addition to the action of a helicopter emergency medical team supporting the patient's transportation from a low-complexity emergency care unit to a specialized unit.
Collapse
Affiliation(s)
- Lilyan Paula de Sousa Teixeira Lima
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Paulo Regis Souza Santos
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Herberth Jessie Martins
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Daniel Augusto de Souza Rodrigues
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | - Larissa Michetti Silva
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Trauma Center of the Federal District, Brasília, Brazil.
| | - Mônica Beatriz Ortolan Libardi
- Mobile Emergency Care Service, Serviço de Atendimento Móvel de Urgência, Brasília, Brazil; Helicopter Emergency Medical Services, Military Firefighters Corps of the Federal District, Brasília, Brazil.
| | | |
Collapse
|
8
|
Imach S, Wafaisade A, Lefering R, Böhmer A, Schieren M, Suárez V, Fröhlich M. The impact of prehospital tranexamic acid on mortality and transfusion requirements: match-pair analysis from the nationwide German TraumaRegister DGU®. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:277. [PMID: 34348782 PMCID: PMC8336395 DOI: 10.1186/s13054-021-03701-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022]
Abstract
Background Outcome data about the use of tranexamic acid (TXA) in civilian patients in mature trauma systems are scarce. The aim of this study was to determine how severely injured patients are affected by the widespread prehospital use of TXA in Germany. Methods The international TraumaRegister DGU® was retrospectively analyzed for severely injured patients with risk of bleeding (2015 until 2019) treated with at least one dose of TXA in the prehospital phase (TXA group). These were matched with patients who had not received prehospital TXA (control group), applying propensity score-based matching. Adult patients (≥ 16) admitted to a trauma center in Germany with an Injury Severity Score (ISS) ≥ 9 points were included. Results The matching yielded two comparable cohorts (n = 2275 in each group), and the mean ISS was 32.4 ± 14.7 in TXA group vs. 32.0 ± 14.5 in control group (p = 0.378). Around a third in both groups received one dose of TXA after hospital admission. TXA patients were significantly more transfused (p = 0.022), but needed significantly less packed red blood cells (p ≤ 0.001) and fresh frozen plasma (p = 0.023), when transfused. Massive transfusion rate was significantly lower in the TXA group (5.5% versus 7.2%, p = 0.015). Mortality was similar except for early mortality after 6 h (p = 0.004) and 12 h (p = 0.045). Among non-survivors hemorrhage as leading cause of death was less in the TXA group (3.0% vs. 4.3%, p = 0.021). Thromboembolic events were not significantly different between both groups (TXA 6.1%, control 4.9%, p = 0.080). Conclusion This is the largest civilian study in which the effect of prehospital TXA use in a mature trauma system has been examined. TXA use in severely injured patients was associated with a significantly lower risk of massive transfusion and lower mortality in the early in-hospital treatment period. Due to repetitive administration, a dose-dependent effect of TXA must be discussed.
Collapse
Affiliation(s)
- Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany.
| | - Arasch Wafaisade
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Andreas Böhmer
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Mark Schieren
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Victor Suárez
- Department II of Internal Medicine (Nephrology, Rheumatology, Diabetes and General Internal Medicine) and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Matthias Fröhlich
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | | |
Collapse
|
9
|
Pekrul I, Schachtner T, Zwißler B, Möhnle P. [Tranexamic acid for bleeding prophylaxis in orthopedic surgery and trauma-standard or customized therapy?]. Anaesthesist 2021; 70:515-521. [PMID: 33620508 PMCID: PMC8190014 DOI: 10.1007/s00101-021-00928-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 11/23/2022]
Abstract
The use of tranexamic acid (TXA) is established in the treatment of bleeding, especially of bleeding due to hyperfibrinolysis. In recent years the prophylactic use of TXA in trauma and orthopedic surgery has increased leading to open questions regarding potentially associated risks and a possible classification as off label use. The available literature provides a sound basis for the recommendation that TXA can be used in these indications provided that an individual risk assessment is done in patients with increased risks for thromboembolic complications. Although the prophylactic use of TXA in orthopedic surgery and trauma is not explicitly listed in the product characteristics, it should not be regarded as an off label use.
Collapse
Affiliation(s)
- Isabell Pekrul
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland
| | - Thomas Schachtner
- Anästhesie und Intensivmedizin, Schön Klinik München Harlaching, München, Deutschland
| | - Bernhard Zwißler
- Klinik für Anaesthesiologie, Universität München (LMU), München, Deutschland
| | - Patrick Möhnle
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Universität München (LMU), Marchioninistr. 15, 81377, München, Deutschland.
| |
Collapse
|
10
|
Almuwallad A, Cole E, Ross J, Perkins Z, Davenport R. The impact of prehospital TXA on mortality among bleeding trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 90:901-907. [PMID: 33605702 DOI: 10.1097/ta.0000000000003120] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic drug associated with improved survival among trauma patients with hemorrhage. Tranexamic acid is considered a primary hemostatic intervention in prehospital for treatment of bleeding alongside blood product transfusion. METHODS A systematic review and meta-analysis was conducted to investigate the impact of prehospital TXA on mortality among trauma patients with bleeding. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advanced Search library which contain the following of databases: EMBASE, Medline, PubMed, BNI, EMCARE, and HMIC. Other databases searched included SCOPUS and the Cochrane Central Register for Clinical Trials Library. Quality assessment tools were applied among included studies; Cochrane Risk of Bias for randomized control trials and Newcastle-Ottawa Scale for cohort observational studies. RESULTS A total of 797 publications were identified from the initial database search. After removing duplicates and applying inclusion/exclusion criteria, four studies were included in the review and meta-analysis which identified a significant survival benefit in patients who received prehospital TXA versus no TXA. Three observational cohort and one randomized control trial were included into the review with a total of 2,347 patients (TXA, 1,169 vs. no TXA, 1,178). There was a significant reduction in 24 hours mortality; odds ratio (OR) of 0.60 (95% confidence interval [CI], 0.37-0.99). No statistical significant differences in 28 days to 30 days mortality; OR of 0.69 (95% CI, 0.47-1.02), or venous thromboembolism OR of 1.49 (95% CI, 0.90-2.46) were found. CONCLUSION This review demonstrates that prehospital TXA is associated with significant reductions in the early (24 hour) mortality of trauma patients with suspected or confirmed hemorrhage but no increase in the incidence of venous thromboembolism. LEVEL OF EVIDENCE Systematic review and meta-analysis. Level I.
Collapse
Affiliation(s)
- Ateeq Almuwallad
- From the Centre for Trauma Science, Blizard Institute (A.A., E.C., J.R., Z.P., R.D.), Queen Mary University, London, United Kingdom; and Emergency Medical Services Department, Faculty of Applied Medical Sciences (A.A.), Jazan University, Kingdom of Saudi Arabia
| | | | | | | | | |
Collapse
|
11
|
David JS, Lambert A, Bouzat P, Incagnoli P, Geay-Baillat AM, Taverna XJ, Inaba K, Maegele M. Fibrinolytic shutdown diagnosed with rotational thromboelastometry represents a moderate form of coagulopathy associated with transfusion requirement and mortality: A retrospective analysis. Eur J Anaesthesiol 2021; 37:170-179. [PMID: 31567468 DOI: 10.1097/eja.0000000000001096] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Viscoelastic techniques have made it possible to describe specific fibrinolytic phenotypes (physiological, hyperfibrinolysis and shutdown) and to establish a relationship of these phenotypes with outcome. However, there remains a debate as to whether shutdown is a state of hypercoagulability or rather a coagulopathy with moderate fibrinolysis and fibrinogen consumption. OBJECTIVES Our objectives were to describe the relationship between fibrinolytic phenotypes and outcomes, and to report the effects of tranexamic acid (TXA) administration. DESIGN This was a retrospective analysis of prospectively acquired data from a trauma registry. SETTING An academic level 1 trauma centre in the Lyon Region, from March 2011 to December 2016. PATIENTS We included all injured patients who had a rotational thromboelastometry analysis at admission. Fibrinolytic phenotypes were determined according to the maximum lysis: shutdown less than 3%, physiological 3 to 15%, hyperfibrinolysis more than 15%. MAIN OUTCOME MEASURE Mortality at 24 h and at hospital discharge. RESULTS During the study period, 473 patients were included with the following phenotypes: physiological (344 patients, 73%), shutdown (107 patients, 23%) and hyperfibrinolysis (22 patients, 5%). There was an increase in injury severity, prothrombin time ratio, fibrin degradation products and transfusion requirements from the physiological to the shutdown and hyperfibrinolysis phenotypes. Prehospital TXA administration increased the rate of shutdown and decreased the maximum lysis value at admission. After adjustment, multivariate analysis showed that fibrinolytic phenotypes, but not TXA, were independently associated with an increased risk of early death and death before hospital discharge: shutdown [odds ratio (95% confidence interval)] 2.4 (1.2 to 4.8) and hyperfibrinolysis 67.9 (7.4 to 624.2). CONCLUSION The results of the current study suggest that shutdown, which is associated with injury severity and mortality, probably reflects a moderate form of coagulopathy and fibrinolysis rather than a hypercoagulopathy. Therefore, the observation of shutdown fibrinolysis on thromboelastography/rotational thromboelastometry should not lead to withholding but rather to the administration of TXA.
Collapse
Affiliation(s)
- Jean-Stephane David
- From the Department of Anaesthesia and Intensive Care, Lyon-Sud Hospital, Hospices Civils de Lyon (J-SD, AL, PI), University Claude Bernard Lyon 1, Lyon (J-SD, AL), Department of Anaesthesia and Intensive Care, Grenoble University Hospital, Grenoble (PB), Department of Haemostasis, Lyon Sud Hospital (A-MG-B), Department of Anaesthesia and Intensive Care, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France (X-JT), Division of Trauma and Critical Care, Department of Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, California, USA (KI) and Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany (MM)
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Iba T, Warkentin TE, Connors JM, Levy JH. Therapeutic strategies in patients with coagulopathy and disseminated intravascular coagulation: awareness of the phase-dependent characteristics. Minerva Med 2021; 112:701-712. [PMID: 33709675 DOI: 10.23736/s0026-4806.21.07469-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Disseminated intravascular coagulation (DIC) has long been understood as a condition where both thrombotic and hemostatic abnormalities coexist. DIC is a difficult complication for clinicians to manage as it is due to multiple underlying complications of pathophysiologic abnormalities in diverse disease states. Ongoing research continues to define the meaning of DIC, evaluate therapeutic options, and how it presents with the complex paradigm of systemic activation of coagulation. In this review we introduce the current topis regarding this tough situation. EVIDENCE ACQUISITION Online search of published medical literature through MEDLINE and Web of Sience using the term "disseminated intravascular coagulation", "coagulopathy", "coagulation disorder", "hemostasis", "fibrinolysis", "thrombus" and "anticoagulants". EVIDENCE SYNTHESIS Articles were chosen for inclusion based on their relevance to disseminated intravascular coagulation, coagulopathy, hemostasis and thrombosis in sepsis, COVID-19, trauma, and obstetrics. Reference lists were reviewed to identify additional relevant articles. CONCLUSIONS DIC is recognized as a pathologically triggered and dysregulated systemic activation of coagulation in response to various noxious stimuli. DIC's phenotype and clinical manifestations can vary from prothrombotic to hemorrhagic, depending on the underlying diseases. However, the fundamental mechanisms of systemic and vascular endothelial dysfunction can be explained as different phases of the acute response, with an initial prothrombotic phase that can commonly change to hemostatic insufficiency. Thrombin is the key initiator of the pathophysiologic process along with endothelial injury and initially fibrinolysis activation followed by fibrinolysis suppression. There is no established approach for managing DIC beyond initially treating the underlying disease and replacement therapy for the management of coagulopathy. Targeting anticoagulation therapy with antithrombin concentrates and recombinant thrombomodulin for the prevention of microthrombus formation, and antifibrinolytic therapy using tranexamic acid for the coagulopathy after massive bleeding, continue to be studied as therapeutic options.
Collapse
Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan -
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Canada
| | - Jean Marie Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
13
|
Upadhyaya GK, Iyengar KP, Jain VK, Garg R. Evolving concepts and strategies in the management of polytrauma patients. J Clin Orthop Trauma 2021; 12:58-65. [PMID: 33716429 PMCID: PMC7920163 DOI: 10.1016/j.jcot.2020.10.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/04/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023] Open
Abstract
Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.
Collapse
Affiliation(s)
- Gaurav K. Upadhyaya
- Department of Orthopaedics, All India Institute of Medical Sciences, Raebareli, UP, 229405, India
| | | | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India
- Corresponding author. Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi, 110001, India.
| | - Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, 110029, India
| |
Collapse
|
14
|
Lier H, Shander A. Tranexamic acid: the king is dead, long live the king! Br J Anaesth 2020; 124:659-662. [DOI: 10.1016/j.bja.2020.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 02/22/2020] [Accepted: 02/23/2020] [Indexed: 12/26/2022] Open
|
15
|
Tencza E, Harrell AJ, Sarangarm P. Effect of tranexamic acid administration time on blood product use in urban trauma patients. Am J Health Syst Pharm 2020; 77:S46-S53. [PMID: 32426833 DOI: 10.1093/ajhp/zxaa074] [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] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To evaluate the effect of time to tranexamic acid administration on blood product usage in trauma patients and to assess the potential benefit of initiating a protocol for field administration by ground ambulance personnel. METHODS Adult patients with traumatic injuries who received 1 g of tranexamic acid during the period January 2014 through June 2016 were retrospectively identified via review of automated dispensing cabinet and electronic medical record data and cross-referencing with the New Mexico Trauma Registry. Exclusion criteria included tranexamic acid use for nontrauma indications, previous admission for trauma during the study period, and a lack of pertinent information regarding the time, type, or severity of trauma in available records. The primary outcome was blood product use (aggregate of units of platelets, packed red blood cells [pRBCs], and fresh frozen plasma [FFP]) in the first 24 hours of hospital admission. RESULTS The analysis included 107 patient cases, with a median transport time of 20 minutes (range, 7-103 minutes); 73% of reported transport times were less than 30 minutes. All patients received a loading dose of tranexamic acid in the hospital, with the exception of 2 patients who received tranexamic acid in the field. Administration of a tranexamic acid loading dose was documented within 3 hours for 90.7% of patients, with a mean time to administration of 91.9 minutes. A mean (SD) total of 14.8 (16.0) units of blood products (range, 0-91 units) were administered, consisting of a mean (SD) of 8.0 (8.4) units of pRBCs (range, 0-48 units), 5.6 (7.5) units of FFP (range, 0-38 units), and 1.2 (1.7) units of platelets (range, 0-7 units). Time to tranexamic acid administration did not affect blood product usage in the first 24 hours of admission after adjusting for potential confounders. CONCLUSION Earlier administration of tranexamic acid was not associated with a decrease in use of blood products. This finding, paired with the relatively short ground transport times typical for our institution, makes it unlikely that field administration of tranexamic acid would benefit the evaluated patient population.
Collapse
Affiliation(s)
- Elizabeth Tencza
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM
| | - Andrew J Harrell
- Department of Emergency Medicine, Division of EMS, Austere, and Tactical Medicine, University of New Mexico, Albuquerque, NM
| | | |
Collapse
|
16
|
Ghaffarpasand F, Abbasi HR, Bolandparvaz S, Paydar S, Dehghankhalili M. Tranexamic Acid; A Glittering Player in the Field of Trauma. Bull Emerg Trauma 2020; 8:53-55. [PMID: 32420388 PMCID: PMC7211392 DOI: 10.30476/beat.2020.46443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Fariborz Ghaffarpasand
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran.,Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Abbasi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Shahram Paydar
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW Massive haemorrhage is a significant cause of mortality and morbidity in a variety of clinical settings, although most research has been related to trauma patients. Military studies from recent conflicts found that higher ratios of plasma to red blood cells (RBCs) were associated with increased survival in injured soldiers, and subsequent trials in civilian populations showed similar decreased mortality. Over the last decade, massive transfusion protocols (MTPs) have become an important component in the treatment of the massively bleeding patient. This review is intended to summarize the more recent findings and trends in massive transfusion. RECENT FINDINGS There have been several observational studies suggesting that higher ratios of plasma to RBC and platelets to RBC are associated with improved survival but there is a paucity of randomized studies relating to specific ratios, dosages, timing, and guidance. Other studies have developed and assessed scoring systems used to initiate MTPs and specific tests used to guide MTPs. Finally, the specific blood components and adjuncts that constitute a MTP are the subject of further ongoing research. SUMMARY The absence of a universal definition of massive bleeding or massive transfusion, heterogeneity in patients suffering from massive bleeding, and the difficulty in predicting which patients will require a massive transfusion all contribute to the difficulty of studying massive transfusion. However, there is evidence that higher plasma : RBC ratios correlate with improved survival, and that adjuncts to transfusion play a key role. Furthermore, recent validations of massive haemorrhage scoring systems should allow more consistent and appropriate triggering of massive transfusions.
Collapse
|
18
|
Raffee LA, Oteir AO, Alawneh KZ, Alustath AMI. Relationship Between Initial Arterial Blood Gases and Coagulation Profiles - Analyzing the Prognosis and Outcomes in Patients with Multiple Injuries/Trauma. Open Access Emerg Med 2020; 12:87-92. [PMID: 32346316 PMCID: PMC7167264 DOI: 10.2147/oaem.s244941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/25/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Trauma is recognized as a significant health concern across the world. The increase in the mortality rate of multiple trauma (MT) patients serves as a major issue for health-care providers. The study investigates the relationship between the initial arterial blood gases and coagulation profiles among the multiple injured/trauma patients. Patients and Methods A retrospective study design was used, and 137 acute trauma patients' data were included from the King Abdullah University Hospital (KAUH) from 1 January 2014 to 1 October 2017. Results The results showed that patients were mainly male (79.6%) and had RTA (71.5%). They had a normal pH (50.4%) and pCO2 (68.6%) while decreasing HCO3 (51.1%). An increasing level of pCO2 (45%) along with PT (28%), PTT (17%) and INR (23%) is observed. It also showed a decreasing level of platelets (39%). The overall findings showed a close association of the blood gases and coagulation indicators. Conclusion The study concludes that to control the coagulation markers, the blood gases of the patients should be screened and monitored.
Collapse
Affiliation(s)
- Liqaa A Raffee
- Department of Accident and Emergency Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| | - Alaa O Oteir
- Program of Paramedicine, Department of Allied Medical Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Khaled Z Alawneh
- Department of Diagnostic Radiology and Nuclear Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Alaa M I Alustath
- Department of Accident and Emergency Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan
| |
Collapse
|
19
|
Ackerman RS, Hirschi M, Trona N, Joyce DM, Evans T, Patel SY. Incidence of Thromboembolic Events in Oncology Patients Receiving Intraoperative Tranexamic Acid During Orthopedic Surgery: A Retrospective Review at a Comprehensive Cancer Center. A A Pract 2020; 14:63-66. [DOI: 10.1213/xaa.0000000000001129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
20
|
Blutungsmanagement: Tranexamsäure in der Präklinik. Pro und Kontra. Notf Rett Med 2019. [DOI: 10.1007/s10049-018-0471-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
21
|
Lier H, Maegele M, Shander A. Tranexamic Acid for Acute Hemorrhage: A Narrative Review of Landmark Studies and a Critical Reappraisal of Its Use Over the Last Decade. Anesth Analg 2019; 129:1574-1584. [PMID: 31743178 DOI: 10.1213/ane.0000000000004389] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The publication of the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) study and its intense dissemination prompted a renaissance for the use of the antifibrinolytic agent tranexamic acid (TXA) in acute trauma hemorrhage. Subsequent studies led to its widespread use as a therapeutic as well as prophylactic agent across different clinical scenarios involving bleeding, such as trauma, postpartum, and orthopedic surgery. However, results from the existing studies are confounded by methodological and statistical ambiguities and are open to varied interpretations. Substantial knowledge gaps remain on dosing, pharmacokinetics, mechanism of action, and clinical applications for TXA. The risk for potential thromboembolic complications with the use of TXA must be balanced against its clinical benefits. The present article aims to provide a critical reappraisal of TXA use over the last decade and a "thought exercise" in the potential downsides of TXA. A more selective and individualized use of TXA, guided by extended and functional coagulation assays, is advocated in the context of the evolving concept of precision medicine.
Collapse
Affiliation(s)
- Heiko Lier
- From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Marc Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Campus Cologne-Merheim, Cologne, Germany
| | - Aryeh Shander
- Department of Anesthesiology, Critical Care Medicine, Hyperbaric Medicine, Englewood Health, TeamHealth Research Institute, Englewood, New Jersey
| |
Collapse
|
22
|
Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury 2019; 50:1656-1670. [PMID: 31558277 DOI: 10.1016/j.injury.2019.09.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. METHODS I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. INCLUSION CRITERIA adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure). RESULTS I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. CONCLUSIONS Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.
Collapse
Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - S Halvachizadeh
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - L Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA, Utrecht, the Netherlands.
| | - G D Velmahos
- Dept. of Trauma, Emergency Surgery and Critical Care, Harvard University, Mass. General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - R Buckley
- Section of Orthopedic Trauma, University of Calgary, Foothills Medical Center, 0490 McCaig Tower, 3134 University Drive NW Calgary, Alberta, T2N 5A1, Canada.
| | - P V Giannoudis
- Trauma & Orthopaedic Surgery, Clarendon Wing, A Floor, Great George Street, Leeds General Infirmary University Hospital, University of Leeds, Leeds, LS1 3EX, UK.
| |
Collapse
|
23
|
Determining the patient at risk - are scoring systems helpful to develop individualized concepts for safe definitive fracture fixation and damage control techniques? Injury 2019; 50:1269-1271. [PMID: 31280866 DOI: 10.1016/j.injury.2019.06.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
24
|
Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 696] [Impact Index Per Article: 139.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
Collapse
Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department 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
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| |
Collapse
|
25
|
Schober P, Giannakopoulos G, Loer SA, Schwarte LA. Hemorrhage Treatment Adjuncts in a Helicopter Emergency Medical Service. Air Med J 2019; 38:209-211. [PMID: 31122589 DOI: 10.1016/j.amj.2019.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 12/15/2018] [Accepted: 01/03/2019] [Indexed: 12/21/2022]
Abstract
Hemorrhaging is the leading cause of preventable death after trauma. In our helicopter emergency medical service (HEMS), we introduced a bundle of 3 hemostatic adjuncts: 1) tourniquet, 2) hemostatic chitosan-based wound packings, and 3) tranexamic acid (TXA). The real-life frequency of applying these adjuncts in HEMS remains unclear. Therefore, we analyzed our electronic HEMS database regarding the use of these hemostatic adjuncts. We analyzed all subsequent dispatches of our HEMS "Lifeliner 1" within a searchable digital database (01.02.2013-22.05.2018). This HEMS operates 24/7, servicing ∼4.5 million inhabitants of the Netherlands. During the 75-month study period, we registered 15,759 dispatches, of which 8,658 were canceled, and 7,101 included on-site patient care, including 4,928 (69.4%) trauma cases. In total, we recorded 78 tourniquet applications (1.1% of patients), 104 hemostatic wound packings (1.5% of patients), and 1,379 cases with prehospital TXA administration (19.4% of patients). This difference in the use of hemostatics has several contributors, including a possible lack of awareness for tourniquets and procoagulant wound packing, a high proportion of blunt trauma with internal bleeding not accessible to tourniquet or wound packing, and a liberal use of TXA (eg, in patients with unproven hemorrhage). Besides creating awareness for those hemostatic adjuncts, the practical implications of our findings need further evaluation in future studies.
Collapse
Affiliation(s)
- Patrick Schober
- Department of Anesthesiology, VU University Medical Center, Amsterdam, Netherlands; Trauma Center, Department of Surgery, VU University Medical Center, Amsterdam, Netherlands
| | | | - Stephan A Loer
- Department of Anesthesiology, VU University Medical Center, Amsterdam, Netherlands; Trauma Center, Department of Surgery, VU University Medical Center, Amsterdam, Netherlands
| | - Lothar A Schwarte
- Department of Anesthesiology, VU University Medical Center, Amsterdam, Netherlands; Trauma Center, Department of Surgery, VU University Medical Center, Amsterdam, Netherlands.
| |
Collapse
|
26
|
Laue F, Ramadanov N, Matthes G. Schockraummanagement beim Schwerverletzten. Notf Rett Med 2019. [DOI: 10.1007/s10049-018-0552-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
27
|
Nathan N. From Foundation to Demolition: The Influence of Perioperative Tranexamic Acid. Anesth Analg 2018; 126:373. [PMID: 29346197 DOI: 10.1213/ane.0000000000002770] [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]
|