Management of non-compressible torso hemorrhage of the abdomen in civilian and military austere environments: a scoping review.

Background: Non-compressible abdominal hemorrhage (NCAH) is the leading cause of potentially preventable deaths in both civilian and military austere environments, and an improvement in mortality due to this problem has not been demonstrated during the past quarter century. Several innovations have been developed to control hemorrhage closer to the point of injury. Objective: This review assessed NCAH interventions in civilian and military settings, focusing on austere environments. It identified innovations, effectiveness, and knowledge gaps for future research. Methodology: The Joanna Briggs Institute for Evidence Synthesis methodology guided this scoping review to completion. Studies evaluating NCAH with human participants in civilian and military austere environments that were eligible for inclusion were limited to English language studies published between December 1990 and January 2023. The PCC (Participant, Concept, Context) framework was used for data synthesis. Deductive and inductive thematic analyses were used to assess the literature that met inclusion criteria, identify patterns/themes to address the research questions and identify common themes within the literature. A stakeholder consultation was conducted to review and provide expert perspectives and opinions on the results of the deductive and inductive thematic analyses. Results: The literature search identified 868 articles; 26 articles met the inclusion criteria. Textual narrative analysis of the 26 articles resulted in the literature addressing four main categories: NCAH, penetrating abdominal trauma, resuscitative endovascular balloon occlusion of the aorta (REBOA), and ResQFoam. The deductive thematic analysis aimed to answer three research questions. Research question 1 addressed the effectiveness of REBOA, damage control resuscitation, and damage control surgery in managing NCAH in austere environments. No effectiveness studies were found on this topic. Research question 2 identified three knowledge gaps in NCAH management in austere environments. The analysis identified early hemorrhage control, prehospital provider decision-making ability, and REBOA implementation as knowledge gaps in NCAH. Research question 3 identified five innovations that may affect the management of NCAH in the future: transport of patients, advanced resuscitative care, expert consultation, REBOA implementation, and self-expanding foam implementation. The inductive thematic analysis resulted in four recurrent themes from the literature: prehospital care, decision-making, hemorrhage control, and mortality in NCAH. During the stakeholders' consultation, the results of the deductive and inductive thematic analyses were reviewed and agreed on by the stakeholders. Special emphasis and discussion were given to prehospital management, expert opinions in the prehospital environment, decision-making in the prehospital environment, transport and resuscitation in the prehospital setting, REBOA, alternative discussion for research, and research gaps. Conclusion: NCAH is still a significant cause of preventable death in both military and civilian austere environments, even with ongoing research and interventions aimed at extending survival in such conditions. This scoping review has identified several potential concepts that could reduce the mortality associated with a preventable cause of death due to hemorrhage in austere environments.

Prior Antibiotic Exposure Is Associated With Reoperation After Elective Non-colorectal Surgery.

BACKGROUND: Recent antibiotic exposure has previously been associated with poor outcomes following elective surgery. The purpose of this study is to evaluate the impact of prior recent antibiotic exposure in a multicenter cohort of Veterans Affairs patients undergoing elective non-colorectal surgery. METHODS: This is a retrospective cohort study of the Veterans Affairs Surgical Quality Improvement Program, including elective, non-cardiovascular, non-colorectal surgery from 2013 to 2017. Outpatient antibiotic exposure within 90 days prior to surgery was identified from the Veterans Affairs outpatient pharmacy database and matched with each case. Primary outcomes included serious complication, any complication, any infection, or surgical site infection. Secondary outcomes included 30-day mortality, length of stay, and Clostridioides difficile infection. RESULTS: Of 21,112 eligible patients, 2885 (13.7%) were exposed to antibiotics within 90 days prior to surgery with a duration of 7 (IQR: 5-10) days and prescribed 42 (IQR: 21-64) days prior to surgical intervention. Compared to non-exposed patients, exposed patients had higher unadjusted complication rates, increased length of stay, and rates of return to the operating. Exposure was independently associated with return to the operating room (OR: 1.39; 99% CI: 1.05-1.84). CONCLUSIONS: Among Veterans, recent antibiotic exposure within 90 days of elective surgery was associated with a 39% increase in the odds of return to the operating room. Further work is needed to evaluate the effects of antibiotic exposure and dysbiosis on surgical outcomes.

Management of non-compressible torso hemorrhage of the abdomen in civilian and military austere/remote environments: protocol for a scoping review.

The management of non-compressible torso hemorrhage in military austere/remote environments is a leading cause of potentially preventable death in the prehospital/battlefield environment that has not shown a decrease in mortality in 26 years. Numerous conceptual innovations to manage non-compressible torso hemorrhage have been developed without proven effectiveness in this setting. This scoping review aims to assess the current literature to define non-compressible torso hemorrhage in civilian and military austere/remote environments, assess current innovations and the effectiveness of these innovations, assess the current knowledge gaps and potential future innovations in the management of non-compressible torso hemorrhage in civilian and military austere/remote environments, and assess the translational health science perspective of the current literature and its potential effect on public health. The Joanna Briggs Institute for evidence synthesis will guide this scoping review to completion. A nine-step development process, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist, will be used to enhance the methodological and reporting quality of this scoping review. The Participant, Concept, Context framework will broaden this scoping review's reach in developing a comprehensive search strategy. Thirty years will be explored to assess all relevant literature to ensure a thorough search. Two researchers will explore all the discovered literature and develop consensus on the selected literature included in this scoping review. The article will undergo review and data extraction for data analysis. The knowledge to action framework will guide the knowledge synthesis and creation of this scoping review. A narrative synthesis will systematically review and synthesize the collected literature to produce and explain a broad conclusion of the selected literature. Lastly, a consultation exercise in the form of qualitative interviews will be conducted to assess the thematic analysis results and validate the result of this scoping review. This scoping review will require Institutional Review Board approval for the expert consultation in the form of qualitative interviews. Consultants' identifying information will remain confidential. The collected and analyzed data from this scoping review will identify gaps in the literature to create an evidence-informed protocol for the management of non-compressible torso hemorrhage of the abdomen in civilian and military austere/remote environments. The results of this scoping review will be distributed in peer-reviewed journals and educational, medical presentations. Scoping Review Protocol, Level IV.

Failure Rate of Prehospital Needle Decompression for Tension Pneumothorax in Trauma Patients.

Tension pneumothorax is commonly treated with needle decompression (ND) at the 2nd intercostal space midclavicular line (2nd ICS MCL) but is thought to have a high failure rate. Few studies have attempted to directly measure the failure rate in patients receiving the intervention. We performed a retrospective analysis of 10 years of patients receiving prehospital ND. CT scans were reviewed to record the location of catheters left indwelling and the proportion of patients who did not have any pneumothorax. Chest wall thickness was measured on both injured and uninjured sides at the 2nd ICS MCL and compared with the recommended alternative, the 5th ICS anterior axillary line (5th ICS AAL). We identified 335 patients that underwent prehospital ND who had CT scans performed. Using our two different radiologic methods of assessing failure, 39 per cent and 76 per cent of attempts at ND failed to reach the pleural space. In addition, at least 39 per cent of patients did not have a tension pneumothorax. Injured chest walls were significantly thicker than uninjured chest walls at both the 2nd ICS MCL and the 5th ICS AAL (both P < 0.005.) Increasing chest wall thickness correlated with the failure of the catheter to reach the pleural space. Using an 8-cm catheter at the 5th ICS AAL, iatrogenic cardiac injury was at risk in 42 per cent of patients. This series confirms the high failure rate of ND at the 2nd ICS MCL, but further studies are needed to assure the safety of using larger catheters at the 5th ICS AAL.

Creation and Efficacy of a Cadaver-Based Prosection Anatomical Course for Critical Care Advanced Practice Providers.

OBJECTIVE: Intensive care units (ICUs) increasingly rely on advanced practice providers (APPs) to care for critically ill patients. Our institutional APPs perceived functional anatomical knowledge deficits. To meet this need, a cadaver-based prosection course was developed. The purpose of our study was to describe and evaluate the learner-perceived course efficacy. DESIGN: A precourse survey collected participant demographics. Precourse and postcourse surveys assessed perceived confidence in 13 anatomical areas. The postcourse survey also evaluated preparedness to perform ICU procedures and to care for postoperative patients, and additionally, gauged participant satisfaction and opinions. Summary statistics and pre-post survey comparisons were performed using Stata 14.0. PARTICIPANTS: Twenty-five APPs, all Advanced Practice Registered Nurse certified and working within our tertiary care ICUs, completed the course. Participants practiced in a variety of ICUs, inclusive of neurologic/neurosurgical (4.0%), burn (8.0%), medical (12.0%), trauma (28.0%) and surgical (48.0%), and typically held a Masters of Science in Nursing as his/her highest attained degree. Experience levels ranged from 0 to 8 years. RESULTS: Precourse survey results confirmed perceived anatomical knowledge deficits, noting median APP scores 3.00 or less, correlating to neutral to very little confidence, in all 13 queried anatomical areas. Wilcoxon signed-rank statistical analysis revealed significantly improved confidence level in anatomic knowledge following course completion in all 13 anatomical areas. Aligning with the improved confidence, most participants felt they were better prepared to perform ICU procedures and care for patients following operative intervention. CONCLUSION: Cadaver-based anatomical training has significant benefit to ICU APPs perceived knowledge and performance.

Rural Trauma Team Development Course decreases time to transfer for trauma patients.

BACKGROUND: The Rural Trauma Team Development Course (RTTDC) is designed to teach knowledge and skills for the initial assessment and stabilization of trauma patients in resource-limited environments. The effect of RTTDC training on transfers from nontrauma centers to definitive care has not been studied. We hypothesized that RTTDC training would decrease referring hospital emergency department (ED) length of stay (LOS), time to call for transfer, pretransfer computed tomography (CT) imaging rate, and mortality rate. METHODS: We conducted a pre/post analysis of trauma patients who were transferred from rural, nontrauma hospitals from 2012 to 2014. Patients from six rural hospitals that participated in an RTTDC course were compared with a control group of similar centers that did not participate in the course. Primary outcome evaluated was referring hospital ED LOS, which was estimated using a difference-in-differences regression model. Secondary outcomes were time to transfer call, pretransfer CT imaging rates, and mortality. RESULTS: Two hundred fifty-three patients were available for study (RTTDC group, n = 130; control group, n = 123). Demographics, CT imaging, and mortality rates were similar between the two groups. In the primary outcome, the RTTDC group experienced an overall 61-minute reduction in referring hospital LOS (p = 0.02) compared with the control group. The RTTDC group also showed a 41-minute reduction (p = 0.03) in time to call for transfer compared with controls. There were no differences in the secondary outcomes of pretransfer CT scanning rates or mortality. CONCLUSIONS: Rural Trauma Team Development Course training shortens ED LOS at rural, nontrauma hospitals by more than 1 hour without increasing mortality. Future educational and research efforts should focus on decreasing unnecessary imaging prior to transfer as well as opportunities to improve mortality rates. This study suggests an important role for RTTDC training in the care of rural trauma patients and may allow trauma centers to recapture the "golden hour" for transferred trauma patients. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Blood transfusion: In the air tonight?

BACKGROUND: The use of prehospital blood transfusion (PBT) in air medical transport has become more widespread. However, the effect of PBT remains unknown. The aim of this study was to examine the impact of PBT on 24-hour and overall in-hospital mortality. METHODS: This is a retrospective cohort study of all trauma patients carried by air medical transport from the scene to a Level I trauma center from 2007 to 2013. We excluded patients who died on the helipad or in the emergency department. Primary outcomes measured were 24-hour and overall in-hospital mortality. Multivariable logistic regressions using all available patient data or the propensity score (for receiving PBT)-matched patient data were performed to study the effect of PBT on these outcomes. RESULTS: Of the 5,581 patients included in the study, 231 (4%) received PBT. Multivariable regression analyses did not show evidence of PBT effect on 24-hour in-hospital mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 0.61-2.44) and on overall in-hospital mortality (OR, 1.20; 95% CI, 0.55-1.79). In addition, using 1:1 propensity score-matched data, the analysis did not show evidence of PBT effect on 24-hour in-hospital mortality (OR, 1.04; 95% CI, 0.54-1.98) and on overall in-hospital mortality (OR, 1.05; 95% CI, 0.56-1.96). Factors associated with increased 24-hour mortality were advanced age, penetrating injury, increased blood transfusion requirement in the first 24 hours, and decreased Glasgow Coma Scale (GCS) score (p < 0.05). These factors were also associated with overall mortality, in addition to increased Injury Severity Score (ISS) (p < 0.05). CONCLUSION: This is the largest study to date of trauma patients who received PBT and were transported from the scene by air medical transport. Our results show no effect of PBT on 24-hour and overall in-hospital mortality. Previous studies also suggest no benefit of PBT, which is counterintuitive to damage-control resuscitation. Prospective data on PBT are needed to assess risk, cost, and benefit. LEVEL OF EVIDENCE: Therapeutic study, level III.

Blast injury: impact on brain and internal organs.

Blast trauma can kill or injure by multiple different mechanisms, not all of which may be obvious on initial presentation. Patients injured by blast effects should be treated as having multisystem trauma and managed according to Advanced Trauma Life Support guidelines. For the most severely injured patients, damage control resuscitation should be practiced until definitive hemorrhage control has been achieved. Patients with blast injuries may present in mass-casualty episodes that can overwhelm local resources. This article reviews some specific injuries, as well as the importance of mild traumatic brain injury. The importance of rehabilitation is discussed.

The evolution of damage control surgery.

The philosophy of damage control surgery has developed tremendously over the past 10 years. It has expanded outside the original boundaries of the abdomen and has been applied to all aspects of trauma care, ranging from resuscitation to limb-threatening vascular injuries. In recent years, the US military has taken the concept to a new level by initiating a damage control approach at the point of injury and continuing it through a transcontinental health care system. This article highlights many recent advances in damage control surgery and discusses proper patient selection and the risks associated with this management strategy.

Treatments for reversing warfarin anticoagulation in patients with acute intracranial hemorrhage: a structured literature review.

STUDY OBJECTIVE: The acute management of patients on warfarin with spontaneous or traumatic intracranial hemorrhage continues to be debated in the medical literature. The objective of this paper was to conduct a structured review of the medical literature and summarize the advantages and risks of the available treatment options for reversing warfarin anticoagulation in patients who present to the emergency department with acute intracranial hemorrhage. METHODS: A structured literature search and review of articles relevant to intracranial hemorrhage and warfarin and treatment in the emergency department was performed. Databases for PubMed, CINAHL, and Cochrane EBM Reviews were electronically searched using keywords covering the concepts of anticoagulation drugs, intracranial hemorrhage (ICH), and treatment. The results generated by the search were limited to English- language articles and reviewed for relevance to our topic. The multiple database searches revealed 586 papers for review for possible inclusion. The final consensus of our comprehensive search strategy was a total of 23 original studies for inclusion in our review. RESULTS: Warfarin not only increases the risk of but also the severity of ICH by causing hematoma expansion. Prothrombin complex concentrate is statistically significantly faster at correcting the INR compared to fresh frozen plasma transfusions. Recombinant factor VIIa appears to rapidly reverse warfarin's effect on INR; however, this treatment is not FDA-approved and is associated with a 5% thromboembolic event rate. Slow intravenous dosing of vitamin K is recommended in patients with ICH. The 30-day risk for ischemic stroke after discontinuation of warfarin therapy was 3-5%. The risks of not reversing the anticoagulation in ICH generally outweigh the risk of thrombosis in the acute setting. CONCLUSIONS: Increasing numbers of patients are on anticoagulation including warfarin. There is no uniform standard for reversing warfarin in intracranial hemorrhage. Intravenous vitamin K in addition to fresh frozen plasma or prothrombin complex concentrate is recommended be used to reverse warfarin-associated intracranial hemorrhage. No mortality benefit for one treatment regimen over another has been shown. Emergency physicians should know their hospital's available warfarin reversal options and be comfortable administering these treatments to critically ill patients.

Postoperative neuromuscular blocker use is associated with higher primary fascial closure rates after damage control laparotomy.

BACKGROUND: Failure to achieve fascial primary closure after damage control laparotomy (DCL) is associated with increased morbidity, higher healthcare expenditures, and a reduction in quality of life. The use of neuromuscular blocking agents (NMBA) to facilitate closure remains controversial and poorly studied. The purpose of this study was to determine whether exposure to NMBA is associated a higher likelihood of primary fascial closure. METHODS: All adult trauma patients admitted between January 2002 and May 2008 who (1) went directly to the operating room, (2) were managed initially by DCL, and (3) survived to undergo a second laparotomy. Study group (NMBA+): those receiving NMBA in the first 24 hours after DCL. Comparison group (NMBA-): those not receiving NMBA in the first 24 hours after DCL. Primary fascial closure defined as fascia-to-fascia approximation by hospital day 7. RESULTS: One hundred ninety-one patients met inclusion (92 in NMBA+ group, 99 in NMBA- group). Although the NMB+ patients were younger (31 years vs. 37 years, p = 0.009), there were no other differences in demographics, severity of injury, or lengths of stay between the groups. However, NMBA+ patients achieved primary closure faster (5.1 days vs. 3.5 days, p = 0.046) and were more likely to achieve closure by day 7 (93% vs. 83%, p = 0.023). After controlling for age, gender, race, mechanism, and severity of injury, logistic regression identified NMBA use as an independent predictor of achieving primary fascial closure by day 7 (OR, 3.24, CI: 1.15-9.16; p = 0.026). CONCLUSIONS: Early NMBA use is associated with faster and more frequent achievement of primary fascial closure in patients initially managed with DCL. Patients exposed to NMBA had a three times higher likelihood of achieving primary fascial closure by hospital day 7.

Multicenter validation of a simplified score to predict massive transfusion in trauma.

BACKGROUND: Several studies have described predictive models to identify trauma patients who require massive transfusion (MT). Early identification of lethal exsanguination may improve survival in this patient population. The purpose of the current study was to validate a simplified score to predict MT at multiple Level I trauma centers. METHODS: All adult trauma patients treated at three Level I trauma centers from July 2006 to June 2007 who (1) were transported directly from the scene, (2) were trauma activations, and (3) received any blood transfusions during admission were included. Assessment of Blood Consumption (ABC) score developed using the same inclusion criteria for patients admitted to a single trauma center (Vanderbilt University Medical Center [VUMC]-1) between July 2005 and June 2006. ABC score calculated by assigning a value (0 or 1) to each of the four parameters: penetrating mechanism, positive focused assessment with sonography for trauma for fluid, arrival blood pressure <90 mm Hg, and arrival pulse >120 bpm. A score of 2 was used as "positive" to predict MT. Area under receiver-operating characteristic curve was calculated to compare the predictive ability of the score at each institution. RESULTS: There were 586 patients in the developmental (VUMC-1), 513 patients at trauma center 1 (VUMC-2), 372 at trauma center 2 (PMH), and 133 at trauma center 3 (Johns Hopkins Hospital). MT rate was similar between centers: 14% to 15%. Sensitivity and specificity for the ABC score predicting MT ranged from 75% to 90% and 67% to 88%, respectively. Correctly classified patients and area under receiver-operating characteristic curve, however, were 84% to 87% and 0.83 to 0.90, respectively. CONCLUSIONS: The ABC score is a valid instrument to predict MT early in the patient's care and across various demographically diverse trauma centers. Future research should focus on this score's ability to prospectively identify patients who will receive MT.

Creation, implementation, and maturation of a massive transfusion protocol for the exsanguinating trauma patient.

The majority of trauma patients (>90%) do not require any blood product transfusion and their mortality is <1%. However, 3% to 5% of civilian trauma patients will receive a massive transfusion (MT), defined as >10 units of packed red blood cells (PRBC) in 24 hours. In addition, more than 25% of these patients will arrive to emergency departments with evidence of trauma-associated coagulopathy. With this combination of massive blood loss and coagulopathy, it has become increasingly more common to transfuse early the trauma patients and with a combination of PRBC, plasma, and platelets. Given the inherent uncertainties common early in the care of patients with severe injuries, the efficient administration of massive amounts of PRBC and clotting factors tends to work best in a predefined, protocol driven system. Our purpose here is to (1) define the problem of massive hemorrhage and coagulopathy in the trauma patient, (2) identify which group of patients this type of protocol should be applied, (3) describe the extensive coordination required to implement this multispecialty MT protocol, (4) explain in detail how the MT was developed and implemented, and (5) emphasize the need for a robust performance improvement or quality improvement process to monitor the implementation of such a protocol and to help identify problems and deliver feedback in a "real-time" fashion. The successful implementation of such a complex process can only be accomplished in a multispecialty setting. Input and representation from departments of Trauma, Critical Care, Anesthesiology, Transfusion Medicine, and Emergency Medicine are necessary to successfully formulate (and implement) such a protocol. Once a protocol has been agreed upon, education of the entire nursing and physician staff is equally essential to the success of this effort. Once implemented, this process may lead to improved clinical outcomes and decreased overall blood utilization with extremely small wastage of vital blood products.

Emergency department blood transfusion predicts early massive transfusion and early blood component requirement.

BACKGROUND: The purpose of this study was to evaluate the ability of uncrossmatched transfusions in the emergency department (ED) to predict early (< 6 hr) massive transfusion (MT) of red blood cells (RBCs) and blood components. STUDY DESIGN AND METHODS: All patients admitted to a Level 1 trauma center between July 2005 and June 2007 who received any transfusions and were transported directly from the scene of injury were included. Early MT was defined as the need for 10 U or more or RBCs in the first 6 hours. Early MT plasma was defined as 6 U or more of plasma in the first 6 hours. Early MT platelets (PLTs) were defined as two or more apheresis transfusions in the first 6 hours. Univariate and multivariate analyses were performed. RESULTS: A total of 485 patients (34%) received ED transfusions (ED RBC+) and 956 (66%) did not receive ED transfusions (ED RBC-). ED RBC+ patients were younger, were more likely to be male, and arrived with more severe injuries. Multivariate regression identified ED transfusion of uncrossmatched RBC as an independent predictor of requiring early MT of RBCs (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.36-7.59; p = 0.001), plasma (OR, 2.7; 95% CI, 1.66-4.39; p < 0.001), and PLTs (OR, 1.9; 95% CI, 1.08-3.41; p = 0.025). CONCLUSION: Patients receiving uncrossmatched RBCs in the ED are more than three times more likely to receive early MT of RBCs. Additionally, patients transfused with ED RBCs are more likely to receive 6 units or more of plasma and two or more apheresis PLT transfusions. Given these findings, ED transfusion of uncrossmatched RBCs should be considered a potential trigger for activation of an institution's MT protocol.

Tips and tricks for the trauma patient.

Interventions on the trauma patient are an essential component of the complete scope of care that is provided to the multiply injured patient today. The active participation by the interventional radiologist along the entire spectrum of clinical care is very important to optimize patient outcomes. Suggestions on how to establish a clinical presence are presented. A few of the newer concepts and terminology applicable to trauma care are reviewed. Tips useful in the trauma room, in the interventional radiology suite, and during the postprocedural period are discussed.

Room for (performance) improvement: provider-related factors associated with poor outcomes in massive transfusion.

BACKGROUND: Massive transfusion (MT) protocols improve survival in patients with exsanguinating hemorrhage. Both the increased plasma to red blood cells (RBC) and platelets to RBC ratios, and the "protocolization" of product delivery seem to be critical components of the reduction in mortality. The purpose of this study was to identify the incidence and impact of MT protocol noncompliance and to intervene in provider-related events associated with poor compliance and outcomes. METHODS: A MT protocol was initiated in 2006 at a Level I trauma center. All cases of protocol activation were reviewed by a multidisciplinary performance improvement (PI) group for compliance and the need for "real-time" protocol adjustments. Educational conferences, Grand Rounds presentations, and individual provider education were performed on a quarterly basis. Compliance of seven measures were evaluated as follows: type and screen sent from emergency department (ED), activation of protocol in ED, activation by trauma attending, administration of 2:3 plasma to RBC, administration of 1:5 platelets to RBC, protocol discontinuation on leaving operating room, and no products wasted. Univariate, multivariate, and time-series analyses were performed. RESULTS: All 125 MT protocol activations occurring from February 2006 to January 2008 were reviewed. Full compliance for all PI measures during the entire period was 27%. There were no differences in demographics, injury severity, or physiologic scores between patients for whom activations were compliant and those who were noncompliant. Full compliance was an independent predictor of survival (86.7% vs. 45.0%, p < 0.001). Both activation of the protocol in the ED and achievement of prespecified ratios of plasma: RBC (2:3) and platelets: RBC (1:5) were independent predictors of 24-hour and 30-day survivals. All PI measures demonstrated improved compliance during the study period with the exception of ED activation. Failure to send type and screen from the ED is an independent predictor of wasted blood products. CONCLUSION: Early activation of a MT protocol and achieving predefined ratios was associated with improved survival. ED activation and direct blood bank notification by the trauma attending were associated with a reduction in blood product wastage. A multidisciplinary PI process helps to identify provider/specialty noncompliance and to assess the impact of these factors, and it was associated with improvement in compliance and MT outcomes over time.

Hyperkalemia following massive transfusion in trauma.

BACKGROUND: Large-volume blood transfusions have been implicated in the development of hyperkalemia. The purpose of the current study was to determine whether critically injured patients receiving massive transfusions are at an increased risk of hyperkalemia. METHODS: Massive transfusion (MT) cohort, all trauma patients (02/2004-01/2008) taken directly to the OR and receiving >or=10 units of RBC in first 24h. Comparison cohort (No-RBC), all patients (02/2004-01/2008) transported directly to the OR who received no blood products in the first 24h. Hyperkalemia defined as K+ > 5.5 mEq/L. RESULTS: There were 266 MT patients, 237 No-RBC patients. MT patients were more likely to have hyperkalemia in the immediate postoperative setting (1.8% versus 4.6%, P = 0.049). However, linear regression did not identify intraoperative blood transfusions as a predictor of postoperative K+ values (P = 0.417). Logistic regression identified only preop K+ (OR 1.79, P = 0.021) and postop pH (OR 0.009, P = 0.001), but not MT, as independent risk factors for postop hyperkalemia. CONCLUSIONS: Despite concerns of hyperkalemia following MT, we found less than a 5% incidence of postop K+ (>5.5 mEq/L). After adjusting for the significant effects of preop K+ and postop pH, MT patients were at no higher risk of hyperkalemia than those who received no blood products.

Transfusion therapy in hemorrhagic shock.

PURPOSE OF REVIEW: Bleeding and death from hemorrhage remain a leading cause of morbidity and mortality in the trauma population. Early resuscitation of these gravely injured patients has changed significantly over the past several years. The concept of damage control resuscitation has expanded significantly with the experience of the US military in southwest Asia. This review will focus on this resuscitation strategy of transfusing blood products (red cells, plasma, and platelets) early and often in the exsanguinating patient. RECENT FINDINGS: In trauma there are no randomized controlled trials comparing the current damage control hematology concept to more traditional resuscitation methods. But the overwhelming conclusion of the data available support the administration of a high ratio of plasma and platelets to packed red blood cells. Several large retrospective studies have shown ratios close to 1: 1 will result in higher survival. SUMMARY: The current evidence supports that the acute coagulopathy of trauma is present in a high percentage of trauma patients. Patients who will require a massive transfusion will have improved outcomes the earlier that this is identified and the earlier that damage control hematology is instituted. Current evidence does not describe the best ratio but the preponderance of the data suggests it should be greater than 2: 3 plasma-to-packed red blood cells.

Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)?

BACKGROUND: Massive transfusion (MT) occurs in about 3% of civilian and 8% of military trauma patients. Although many centers have implemented MT protocols, most do not have a standardized initiation policy. The purpose of this study was to validate previously described MT scoring systems and compare these to a simplified nonlaboratory dependent scoring system (Assessment of Blood Consumption [ABC] score). METHODS: Retrospective cohort of all level I adult trauma patients transported directly from the scene (July 2005 to June 2006). Trauma-Associated Severe Hemorrhage (TASH) and McLaughlin scores calculated according to published methods. ABC score was assigned based on four nonweighted parameters: penetrating mechanism, positive focused assessment sonography for trauma, arrival systolic blood pressure of 90 mm Hg or less, and arrival heart rate > or = 120 bpm. Area under the receiver operating characteristic curve (AUROC) used to compare scoring systems. RESULTS: Five hundred ninety-six patients were available for analysis; and the overall MT rate of 12.4%. Patients receiving MT had higher TASH (median, 6 vs. 13; p < 0.001), McLaughlin (median, 2.4 vs. 3.4; p < 0.001) and ABC (median, 1 vs. 2; p < 0.001) scores. TASH (AUROC = 0.842), McLaughlin (AUROC = 0.846), and ABC (AUROC = 0.842) scores were all good predictors of MT, and the difference between the scores was not statistically significant. ABC score of 2 or greater was 75% sensitive and 86% specific for predicting MT (correctly classified 85%). CONCLUSIONS: The ABC score, which uses nonlaboratory, nonweighted parameters, is a simple and accurate in identifying patients who will require MT as compared with those previously published scores.