Artificial intelligence and machine learning for hemorrhagic trauma care.

Artificial intelligence (AI), a branch of machine learning (ML) has been increasingly employed in the research of trauma in various aspects. Hemorrhage is the most common cause of trauma-related death. To better elucidate the current role of AI and contribute to future development of ML in trauma care, we conducted a review focused on the use of ML in the diagnosis or treatment strategy of traumatic hemorrhage. A literature search was carried out on PubMed and Google scholar. Titles and abstracts were screened and, if deemed appropriate, the full articles were reviewed. We included 89 studies in the review. These studies could be grouped into five areas: (1) prediction of outcomes; (2) risk assessment and injury severity for triage; (3) prediction of transfusions; (4) detection of hemorrhage; and (5) prediction of coagulopathy. Performance analysis of ML in comparison with current standards for trauma care showed that most studies demonstrated the benefits of ML models. However, most studies were retrospective, focused on prediction of mortality, and development of patient outcome scoring systems. Few studies performed model assessment via test datasets obtained from different sources. Prediction models for transfusions and coagulopathy have been developed, but none is in widespread use. AI-enabled ML-driven technology is becoming integral part of the whole course of trauma care. Comparison and application of ML algorithms using different datasets from initial training, testing and validation in prospective and randomized controlled trials are warranted for provision of decision support for individualized patient care as far forward as possible.

Massive Hemorrhage Protocol: A Practical Approach to the Bleeding Trauma Patient.

Damage-control resuscitation is the standard of care for the hemorrhaging trauma patient. This approach combines rapid hemostasis and early-ratio-based blood product administration. These patients often require initiation of a massive hemorrhage protocol to support the systematic and coordinated delivery of care during this critical phase of resuscitation. Emerging evidence supports that this includes more than blood product administration alone but rather a comprehensive suite of treatments. In this article, we review the existing evidence and provide a pragmatic framework, the 7 Ts of massive hemorrhage protocol, to guide the care of patients with life-threatening traumatic hemorrhage.

Evaluating the Tactical Combat Casualty Care principles in civilian and military settings: systematic review, knowledge gap analysis and recommendations for future research.

OBJECTIVES: The Tactical Combat Casualty Care (TCCC) guidelines detail resuscitation practices in prehospital and austere environments. We sought to review the content and quality of the current TCCC and civilian prehospital literature and characterize knowledge gaps to offer recommendations for future research. METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were searched for studies assessing intervention techniques and devices used in civilian and military prehospital settings that could be applied to TCCC guidelines. Screening and data extraction were performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Quality appraisal was conducted using appropriate tools. RESULTS: Ninety-two percent (n=57) of studies were observational. Most randomized trials had low risk of bias, whereas observational studies had higher risk of bias. Interventions of massive hemorrhage control (n=17) were wound dressings and tourniquets, suggesting effective hemodynamic control. Airway management interventions (n=7) had high success rates with improved outcomes. Interventions of respiratory management (n=12) reported low success with needle decompression. Studies assessing circulation (n=18) had higher quality of evidence and suggested improved outcomes with component hemostatic therapy. Hypothermia prevention interventions (n=2) were generally effective. Other studies identified assessed the use of extended focused assessment with sonography in trauma (n=3) and mixed interventions (n=2). CONCLUSIONS: The evidence was largely non-randomized with heterogeneous populations, interventions, and outcomes, precluding robust conclusions in most subjects addressed in the review. Knowledge gaps identified included the use of blood products and concentrate of clotting factors in the prehospital setting. LEVEL OF EVIDENCE: Systematic review, level III.

Protocol for a multicentre, randomised, parallel-control, superiority trial comparing administration of clotting factor concentrates with a standard massive haemorrhage protocol in severely bleeding trauma patients: the FiiRST 2 trial (a 2020 EAST multicentre trial).

INTRODUCTION: Acute traumatic coagulopathy (ATC) in bleeding trauma patients increase in-hospital mortality. Fibrinogen concentrate (FC) and prothrombin complex concentrate (PCC) are two purified concentrates of clotting factors that have been used to treat ATC. However, there is a knowledge gap on their use compared with the standard of care, the transfusion of plasma. METHODS AND ANALYSIS: The factors in the initial resuscitation of severe trauma 2 trial is a multicentre, randomised, parallel-control, single-blinded, phase IV superiority trial. The study aims to address efficacy and safety of the early use of FC and PCC compared with a plasma-based resuscitation. Adult trauma patients requiring massive haemorrhage protocol activation on hospital arrival will receive FC 4 g and PCC 2000 IU or plasma 4 U, based on random allocation. The primary outcome is a composite of the cumulative number of all units of red cells, plasma and platelets transfused within 24 hours following admission. Secondary outcomes include measures of efficacy and safety of the intervention. Enrolment of 350 patients will provide an initial power >80% to demonstrate superiority for the primary outcome. After enrolment of 120 patients, a preplanned adaptive interim analysis will be conducted to reassess assumptions, check for early superiority demonstration or reassess the sample size for remainder of the study. ETHICS AND DISSEMINATION: The study has been approved by local and provincial research ethics boards and will be conducted according to the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. As per the Tri-Council Policy Statement, patient consent will be deferred due to the emergency nature of the interventions. If superiority is established, results will have a major impact on clinical practice by reducing exposure to non-virally inactivated blood products, shortening the time for administration of clotting factors, correct coagulopathy more efficaciously and reduce the reliance on AB plasma. TRIAL REGISTRATION NUMBER: NCT04534751, pre results.

Freeze-dried plasma for major trauma - Systematic review and meta-analysis.

BACKGROUND: Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma. STUDY DESIGN AND METHODS: Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile. RESULTS: Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP. CONCLUSION: Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality). LEVEL OF EVIDENCE: Systematic review and meta-analysis, level IV.

Quality of Reporting on Guideline, Protocol, or Algorithm Implementation in Adult Trauma Centers: A Systematic Review.

OBJECTIVE: To appraise the quality of reporting on guideline, protocol, and algorithm implementations in adult trauma settings according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). BACKGROUND: At present we do not know if published reports of guideline implementations in trauma settings are of sufficient quality to facilitate replication by other centers wishing to implement the same or similar guidelines. METHODS: A systematic review of the literature was conducted. Articles were identified through electronic databases and hand searching relevant trauma journals. Studies meeting inclusion criteria focused on a guideline, protocol, or algorithm that targeted adult trauma patients ≥18 years and/or trauma patient care providers, and evaluated the effectiveness of guideline, protocol, or algorithm implementation in terms of change in clinical practice or patient outcomes. Each included study was assessed in duplicate for adherence to the 18-item SQUIRE 2.0 criteria. The primary endpoint was the proportion of studies meeting at least 80% (score ≥15) of SQUIRE 2.0. RESULTS: Of 7368 screened studies, 74 met inclusion criteria. Thirty-nine percent of studies scored ≥80% on SQUIRE 2.0. Criteria that were met most frequently were abstract (93%), problem description (93%), and specific aims (89%). The lowest scores appeared in the funding (28%), context (47%), and results (54%) criteria. No study indicated using SQUIRE 2.0 as a guideline to writing the report. CONCLUSIONS: Significant opportunity exists to improve the utility of guideline implementation reports in adult trauma settings, particularly in the domains of study context and the implications of context for study outcomes.

Primary aeromedical retrieval crew composition: Do different teams impact clinical outcomes? A descriptive systematic review.

OBJECTIVES: Military Forward Aeromedical Evacuation and civilian Helicopter Emergency Medical Services are widely used to conduct Primary Aeromedical Retrieval. Crew composition in Primary Aeromedical Retrieval missions varies considerably. The ideal composition is unknown. Thus, we conducted a descriptive systematic review on mortality and other outcomes for different Primary Aeromedical Retrieval crew compositions. METHODS: Medline, Embase, and Cochrane Controlled Trials Register were searched up to January 2020. Results were reported per Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Studies of adult trauma air transported by different crews were included. Population, injury severity, crew composition, procedures, and outcomes, including mortality, were abstracted. Risk of bias was assessed using previously validated tools. A lack of reported effect measures precluded a quantitative analysis. RESULTS: Sixteen studies met inclusion criteria (3 prospective studies, 1 case-control, and 12 retrospective). Overall, studies reported a mortality benefit associated with advanced health care providers. This was most apparent in patients with severe but survivable injuries. In this population, early rapid sequence induction, endotracheal intubation, mechanical ventilation, thoracostomies, blood products transfusion, and treatment of hemorrhagic shock are better performed by advanced providers and may improve outcomes. The quality of evidence reported a moderate risk of bias in the included studies. CONCLUSIONS: Overall, findings were divergent but showed a trend to decreased mortality in patients treated by advanced providers with interventions beyond the basic paramedic level. This trend was most significant in patients with severe but survivable injuries. These results should be cautiously interpreted because most studies were observational, had small sample sizes, and had a high potential for confounding factors.

Cryoprecipitate transfusion in bleeding patients.

OBJECTIVES: The management of acquired coagulopathy in multiple clinical settings frequently involves fibrinogen supplementation. Cryoprecipitate, a multidonor product, is widely used for the treatment of acquired hypofibrinogenemia following massive bleeding, but it has been associated with adverse events. We aimed to review the latest evidence on cryoprecipitate for treatment of bleeding. METHODS: We conducted a narrative review of current literature on cryoprecipitate therapy, describing its history, formulations and preparation, and recommended dosing. We also reviewed guideline recommendations on the use of cryoprecipitate in bleeding situations and recent studies on its efficacy and safety. RESULTS: Cryoprecipitate has a relatively high fibrinogen content; however, as it is produced by pooling fresh frozen donor plasma, the fibrinogen content per unit can vary considerably. Current guidelines suggest that cryoprecipitate use should be limited to treating hypofibrinogenemia in patients with clinical bleeding. Until recently, cryoprecipitate was deemed unsuitable for pathogen reduction, and potential safety concerns and lack of standardized fibrinogen content have led to some professional bodies recommending that cryoprecipitate is only indicated for the treatment of bleeding and hypofibrinogenemia in perioperative settings where fibrinogen concentrate is not available. While cryoprecipitate is effective in increasing plasma fibrinogen levels, data on its clinical efficacy are limited. CONCLUSIONS: There is a lack of robust evidence to support the use of cryoprecipitate in bleeding patients, with few prospective, randomized clinical trials performed to date. Clinical trials in bleeding settings are needed to investigate the safety and efficacy of cryoprecipitate and to determine its optimal use and administration.

Does the evidence support the importance of high transfusion ratios of plasma and platelets to red blood cells in improving outcomes in severely injured patients: a systematic review and meta-analyses.

BACKGROUND: Deaths by exsanguination in trauma are preventable with hemorrhage control and resuscitation with allogeneic blood products (ABPs). The ideal transfusion ratio is unknown. We compared efficacy and safety of high transfusion ratios of FFP:RBC and PLT:RBC with low ratios in trauma. STUDY DESIGN AND METHODS: Medline, Embase, Cochrane, and Controlled Clinical Trials Register were searched. Observational and randomized data were included. Risk of bias was assessed using validated tools. Primary outcome was 24-h and 30-day mortality. Secondary outcomes were exposure to ABPs and improvement of coagulopathy. Meta-analysis was conducted using a random-effects model. Strength and evidence quality were graded using GRADE profile RESULTS: 55 studies were included (2 randomized and 53 observational), with low and moderate risk of bias, respectively, and overall low evidence quality. The two RCTs showed no mortality difference (odds ratio [OR], 1.35; 95% confidence interval [CI], 0.40-4.59). Observational studies reported lower mortality in high FFP:RBCs ratio (OR, 0.38 [95% CI, 0.22-0.68] for 1:1 vs. <1:1; OR, 0.42 [95% CI, 0.22-0.81] for 1:1.5 vs. <1:1.5; and OR, 0.47 [95% CI, 0.31-0.71] for 1:2 vs. <1:2, respectively). Meta-analyses in observational studies showed no difference in exposure to ABPs. No data on coagulopathy for meta-analysis was identified. CONCLUSIONS: Meta-analyses in observational studies suggest survival benefit and no difference in exposure to ABPs. No survival benefit in RCTs was identified. These conflicting results should be interpreted with caution. Studies are mostly observational, with relatively small sample sizes, nonrandom treatment allocation, and high potential for confounding. Further research is warranted.

What is the quality of reporting on guideline, protocol or algorithm implementation in adult trauma centres? Protocol for a systematic review.

INTRODUCTION: Quality improvement (QI) is mandatory in trauma centres but there is no prescription for doing successful QI. Considerable variation in implementation strategies and inconsistent use of evidence-based protocols therefore exist across centres. The quality of reporting on these strategies may limit the transferability of successful initiatives across centres. This systematic review will assess the quality of reporting on guideline, protocol or algorithm implementation within a trauma centre in terms of the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). METHODS AND ANALYSIS: We will search for English language articles published after 2010 in EMBASE, MEDLINE, CINAHL electronic databases and the Cochrane Central Register of Controlled Trials. The database search will be supplemented by searching trial registries and grey literature online. Included studies will evaluate the effectiveness of guideline implementation in terms of change in clinical practice or improvement in patient outcomes. The primary outcome will be a global score reporting the proportion of studies respecting at least 80% of the SQUIRE 2.0 criteria and will be obtained based on the 18-items identified in the SQUIRE 2.0 guidelines. Secondary outcome will be the risk of bias assessed with the Risk Of Bias In Non-randomised Studies- of Interventions tool for observational cohort studies and with the Cochrane Collaboration tool for randomised controlled trials. Meta-analyses will be conducted in randomised controlled trials to estimate the effectiveness of guideline implementation if studies are not heterogeneous. If meta-analyses are conducted, we will combine studies according to the risk of bias (low, moderate or high/unclear) in subgroup analyses. All study titles, abstracts and full-text screening will be completed independently and in duplicate by the review team members. Data extraction and risk of bias assessment will also be done independently and in duplicate. ETHICS AND DISSEMINATION: Results will be disseminated through scientific publication and conferences. PROSPERO REGISTRATION NUMBER: CRD42018084273.

The Value of Live Tissue Training for Combat Casualty Care: A Survey of Canadian Combat Medics With Battlefield Experience in Afghanistan.

INTRODUCTION: The optimum method for training military personnel for combat casualty care is unknown. In particular, there is debate regarding the incremental benefit of live animal tissue training (LTT) over inanimate human patient simulators (HPSs). Although both LTT and HPS are currently used for predeployment training, the efficacy of these models has not been established. MATERIALS AND METHODS: Canadian Armed Forces combat medics, deployed to Afghanistan between 2006 and 2011, were surveyed retrospectively regarding their experience with combat casualty care and predeployment training. HPSs were used to prepare these combat medics for early rotations. In later years, personnel received a combination of training modalities including HPS and LTT, using anaesthetized porcine models in accordance with appropriate animal care standards. Among those deployed on multiple rotations, there was a cohort who was prepared for deployment using only HPS training, and who later were prepared using mixed-modality training, which included LTT. We asked these medics to compare their predeployment training using HPS only versus their mixed-modality training in how each training package prepared them for battlefield trauma care. RESULTS: Thirty-eight individuals responded, with 20 respondents deployed on multiple rotations. Respondents performed life-saving skills during 89% of the rotations. Self-perceived competence and preparedness were notably higher after incorporation of LTT than after HPS alone. Of 17 respondents deployed on both early and late rotations, the majority felt the latter training was more worthwhile. In addition, almost all individuals felt that LTT should be added to HPS training. Narrative comments described multiple benefits of adding LTT to other types of training. CONCLUSIONS: Among many experienced Canadian Armed Forces personnel, LTT is considered essential predeployment preparation. Individuals who experienced only HPS training before active duty on their first combat deployment reported feeling more competent on subsequent combat deployments after the addition of live tissue models. IMPACT: There has been a movement away from the use of LTT in preparing combat medics for deployment. This article suggests that we should reconsider any decision to completely exclude Live Tissue Training as part of our training plan for combat medics. RECOMMENDATIONS: Military medical organizations should consider judiciously incorporating LTT with human patient simulation training to prepare combat medics for treating battlefield trauma.

Efficacy and safety of the drugs used to reverse direct oral anticoagulants: a systematic review and meta-analysis.

BACKGROUND: Direct oral anticoagulants (DOACs) are effective and safe for prophylaxis and treatment of thromboembolic phenomena. However, managing DOACs during bleeding emergencies is challenging. A systematic review and meta-analysis was conducted on studies addressing efficacy and safety of the drugs used for reversal of DOACs. STUDY DESIGN AND METHODS: Medline, Embase, Cochrane Library, and ClinicalTrials.gov were searched up to September 2016. Studies that examined clinical and laboratory effects of drugs used to reverse DOACs were included. Risk of bias was assessed using Newcastle-Ottawa scale and Cochrane Collaboration tool. Primary and secondary outcomes assessed were reversal of clinical bleeding, clotting assays, and safety, respectively. Overall effect estimates were pooled, and clinical and statistical heterogeneity were assessed. Meta-analysis was conducted using random-effects model. RESULTS: Four cohort studies in bleeding patients (n = 230) and eight randomized controlled trials in healthy volunteers (n = 381) were included, both with moderate risk of bias. Reversal of clotting assays in healthy volunteers was frequently reported, demonstrating that prothrombin complex concentrate (PCC) reversed prothrombin time (PT) and endogenous thrombin potential (ETP) substantially. For PT, pooled mean difference was 1.68 seconds (95% confidence interval [CI], -0.33 to 3.70 sec; p < 0.01; I2  = 97%). For ETP, pooled mean difference was 2.16 seconds (95% CI, 0.57 to 3.75 sec; p < 0.01; I2  =  98%). Andexanet alfa and idarucizumab both reverse clotting assays. No important safety concerns were identified. CONCLUSIONS: Clotting assays are partially reversed by PCC in healthy volunteers. Idarucizumab and andexanet alfa have solid laboratory reversal effect and potential to be clinically efficacious and safe. However, clinical evidence is still lacking for all agents.

Catecholamines as outcome markers in isolated traumatic brain injury: the COMA-TBI study.

BACKGROUND: Elevated catecholamine levels might be associated with unfavorable outcome after traumatic brain injury (TBI). We investigated the association between catecholamine levels in the first 24 h post-trauma and functional outcome in patients with isolated moderate-to-severe TBI. METHODS: A cohort of 174 patients who sustained isolated blunt TBI was prospectively enrolled from three Level-1 Trauma Centers. Epinephrine (Epi) and norepinephrine (NE) concentrations were measured at admission (baseline), 6, 12 and 24 h post-injury. Outcome was assessed at 6 months by the extended Glasgow Outcome Scale (GOSE) score. Fractional polynomial plots and logistic regression models (fixed and random effects) were used to study the association between catecholamine levels and outcome. Effect size was reported as the odds ratio (OR) associated with one logarithmic change in catecholamine level. RESULTS: At 6 months, 109 patients (62.6%) had an unfavorable outcome (GOSE 5-8 vs. 1-4), including 51 deaths (29.3%). Higher admission levels of Epi were associated with a higher risk of unfavorable outcome (OR, 2.04, 95% CI: 1.31-3.18, p = 0.002) and mortality (OR, 2.86, 95% CI: 1.62-5.01, p = 0.001). Higher admission levels of NE were associated with higher risk of unfavorable outcome (OR, 1.59, 95% CI: 1.07-2.35, p = 0.022) but not mortality (OR, 1.45, 95% CI: 0.98-2.17, p = 0.07). There was no relationship between the changes in Epi levels over time and mortality or unfavorable outcome. Changes in NE levels with time were statistically associated with a higher risk of mortality, but the changes had no relation to unfavorable outcome. CONCLUSIONS: Elevated circulating catecholamines, especially Epi levels on hospital admission, are independently associated with functional outcome and mortality after isolated moderate-to-severe TBI.

Systematic Review of Human and Animal Studies Examining the Efficacy and Safety of N-Acetylcysteine (NAC) and N-Acetylcysteine Amide (NACA) in Traumatic Brain Injury: Impact on Neurofunctional Outcome and Biomarkers of Oxidative Stress and Inflammation.

BACKGROUND: No new therapies for traumatic brain injury (TBI) have been officially translated into current practice. At the tissue and cellular level, both inflammatory and oxidative processes may be exacerbated post-injury and contribute to further brain damage. N-acetylcysteine (NAC) has the potential to downregulate both processes. This review focuses on the potential neuroprotective utility of NAC and N-acetylcysteine amide (NACA) post-TBI. METHODS: Medline, Embase, Cochrane Library, and ClinicalTrials.gov were searched up to July 2017. Studies that examined clinical and laboratory effects of NAC and NACA post-TBI in human and animal studies were included. Risk of bias was assessed in human and animal studies according to the design of each study (randomized or not). The primary outcome assessed was the effect of NAC/NACA treatment on functional outcome, while secondary outcomes included the impact on biomarkers of inflammation and oxidation. Due to the clinical and methodological heterogeneity observed across studies, no meta-analyses were conducted. RESULTS: Our analyses revealed only three human trials, including two randomized controlled trials (RCTs) and 20 animal studies conducted using standardized animal models of brain injury. The two RCTs reported improvement in the functional outcome post-NAC/NACA administration. Overall, the evidence from animal studies is more robust and demonstrated substantial improvement of cognition and psychomotor performance following NAC/NACA use. Animal studies also reported significantly more cortical sparing, reduced apoptosis, and lower levels of biomarkers of inflammation and oxidative stress. No safety concerns were reported in any of the studies included in this analysis. CONCLUSION: Evidence from the animal literature demonstrates a robust association for the prophylactic application of NAC and NACA post-TBI with improved neurofunctional outcomes and downregulation of inflammatory and oxidative stress markers at the tissue level. While a growing body of scientific literature suggests putative beneficial effects of NAC/NACA treatment for TBI, the lack of well-designed and controlled clinical investigations, evaluating therapeutic outcomes, prognostic biomarkers, and safety profiles, limits definitive interpretation and recommendations for its application in humans at this time.

A systematic review on the rotational thrombelastometry (ROTEM®) values for the diagnosis of coagulopathy, prediction and guidance of blood transfusion and prediction of mortality in trauma patients.

INTRODUCTION: Viscoelastic assays have been promoted as an improvement over traditional coagulation tests in the management of trauma patients. Rotational thromboelastometry (ROTEM®) has been used to diagnose coagulopathy and guide hemostatic therapy in trauma. This systematic review of clinical studies in trauma investigates the ROTEM® parameters thresholds used for the diagnosing coagulopathy, predicting and guiding transfusion and predicting mortality. METHODS: Systematic literature search was performed using MEDLINE, EMBASE and Cochrane databases. We included studies without restricting year of publication, language or geographic location. Original studies reporting the thresholds of ROTEM® parameters in the diagnosis or management of coagulopathy in trauma patients were included. Data on patient demographics, measures of coagulopathy, transfusion and mortality were extracted. We reported our findings according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Quality assessment and risk of bias were performed using Newcastle Ottawa Scale (NOS) and the quality assessment of diagnostic accuracy studies (QUADAS-2) tools, respectively. RESULTS: A total of 13 observational studies involving 2835 adult trauma patients met the inclusion criteria. Nine studies were prospective and four were retrospective. There were no randomized controlled trials. The quality of the included studies was moderate (mean NOS 5.92, standard deviation 0.26). Using QUADAS-2, only 1 study (7.6 %) had low risk of bias in all domains, and 9 studies (69.2 %) had low risk of applicability concerns. Outcomes from 13 studies were grouped into three categories: diagnosis of coagulopathy (n = 10), prediction of massive transfusion or transfusion guidance (n = 6) and prediction of mortality (n = 6). Overall, specific ROTEM® parameters measured (clot amplitude and lysis) in the extrinsically activated test (EXTEM) and the fibrin-based extrinsically activated test (FIBTEM) were consistently associated with the diagnosis of coagulopathy, increased risk of bleeding and massive transfusion, and prediction of mortality. Presence of hyperfibrinolysis by ROTEM® was associated with increased mortality. CONCLUSIONS: Most of the evidence indicates that abnormal EXTEM and FIBTEM clot amplitude (CA5, CA10) or maximal clot firmness (MCF) diagnose coagulopathy, and predict blood transfusion and mortality. The presence of fibrinolysis (abnormal lysis index [LI30] or maximum lysis [ML]) was also associated with mortality. ROTEM® thus, may be of value in the early management of trauma patients.

Current use of live tissue training in trauma: a descriptive systematic review.

BACKGROUND: Growing public concern for animal welfare, advances in computerized simulation and economic barriers have drawn a critical eye to the use of live tissue training (LTT) in trauma skills acquisition. As a consequence, other simulation methods have replaced LTT, for example, in the Advanced Trauma Life Support (ATLS) course. Owing to the lack of clear conclusions in the literature, we conducted a systematic review to determine the value of LTT alone and in comparison to other simulation methods in trauma. METHODS: We performed a systematic review of the literature considering observational studies and randomized controlled trials (RCTs) that examined LTT in trauma exclusively or compared with other simulation methods. Independently and in duplicate, we adjudicated studies for inclusion and data abstraction. We assessed the quality and risk of bias. RESULTS: Twelve studies met our inclusion criteria: 2 RCTs and 10 prospective cohort studies. Eight and 4 studies were performed in the military and in the civilian settings, respectively. Anesthetized swine were used in 8 studies and goats in 1. The cohort studies involved LTT alone. Different adjunctive training modalities were included: mannequins in 6 studies, cadavers in 2, computer simulation in 1, video presentations in 2 and wound moulage scenarios in 1. The overall methodological quality was moderate as per the Newcastle-Ottawa score (mean 6.0 ± 0, possible range 1-9). The 2 RCTs did not demonstrate adequate random sequence generation and allocation concealment. CONCLUSION: There is limited evidence that other types of simulation are better than LTT. Data on training effects of LTT versus other simulations on outcomes are lacking.

CONTEXTE: Les préoccupations croissantes du public envers le bien-être des animaux, le perfectionnement des dispositifs de simulation informatisés et les contraintes budgétaires ont remis en question la formation sur tissus vivant (FTV) pour l'acquisition des compétences en traumatologie. Par conséquent, d'autres méthodes de simulation ont remplacé la FTV, par exemple, le cours ATLS (Advanced Trauma Life Support ­ Cours avancé de réanimation des polytraumatisés). Étant donné l'absence de conclusions claires dans la littérature, nous avons procédé à une revue systématique afin de comparer la valeur de la FTV seule à celle d'autres méthodes de simulation en traumatologie. MÉTHODES: Nous avons procédé à une revue systématique de la littérature, plus particulièrement des études d'observation et des essais randomisés et contrôlés (ERC) portant exclusivement sur la FTV en traumatologie ou en comparaison avec d'autres méthodes de simulation. De manière indépendante et dupliquée, nous avons sélectionné les études à inclure et nous en avons extrait les données. Nous avons évalué la qualité et le risque de biais. RÉSULTANTS: Douze études répondaient aux critères d'inclusion : 2 ERC et 10 études de cohorte prospectives. Huit et 4 études ont été effectuées dans des contextes militaires et civils, respectivement. Des porcs anesthésiés ont été utilisés pour 8 études et des chèvres pour une étude. Les études de cohorte ne concernaient que la FTV. Les différentes modalités de formation complémentaires incluaient : mannequins dans 6 études, cadavres dans 2 études, simulation par ordinateur dans 1 étude, présentations vidéo dans 2 études et scénarios de moulage de plaies dans 1 étude. La qualité méthodologique globale s'est révélée modérée selon le score Newcastle­Ottawa (moyenne 6,0 ± 0, éventail de valeurs possibles 1­9). Les 2 ERC ne disposaient pas de séquences aléatoires adéquates et l'attribution des traitement n'y était pas effectuée à l'insu. CONCLUSION: Les preuves dont on dispose pour déterminer si d'autres types de simulation sont préférables à la FTV sont limitées. On manque de données comparatives concernant les effets de la FTV sur l'issue des interventions par rapport à d'autres types de simulations.

Fresh whole blood transfusion capability for Special Operations Forces.

Fresh whole blood (FWB) transfusion is an option for providing volume and oxygen carrying capacity to bleeding Special Operations soldiers who are injured in an austere environment and who are far from a regular blood bank. Retrospective data from recent conflicts in Iraq and Afghanistan show an association between the use of FWB and survival. We reviewed the literature to document the issues surrounding FWB transfusion to Special Operations soldiers in the austere environment and surveyed the literature regarding best practice guidelines for and patient outcomes after FWB transfusions. Most literature regarding FWB transfusion is retrospective or historical. There is limited prospective evidence currently to change transfusion practice in tertiary care facilities, but FWB remains an option in the austere setting.

Effect of thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) on diagnosis of coagulopathy, transfusion guidance and mortality in trauma: descriptive systematic review.

INTRODUCTION: The understanding of coagulopathies in trauma has increased interest in thromboelastography (TEG®) and thromboelastometry (ROTEM®), which promptly evaluate the entire clotting process and may guide blood product therapy. Our objective was to review the evidence for their role in diagnosing early coagulopathies, guiding blood transfusion, and reducing mortality in injured patients. METHODS: We considered observational studies and randomized controlled trials (MEDLINE, EMBASE, and Cochrane databases) to February 2014 that examined TEG®/ROTEM® in adult trauma patients. We extracted data on demographics, diagnosis of early coagulopathies, blood transfusion, and mortality. We assessed methodologic quality by using the Newcastle-Ottawa scale (NOS) for observational studies and QUADAS-2 tool for diagnostic accuracy studies. RESULTS: Fifty-five studies (12,489 patients) met inclusion criteria, including 38 prospective cohort studies, 15 retrospective cohort studies, two before-after studies, and no randomized trials. Methodologic quality was moderate (mean NOS score, 6.07; standard deviation, 0.49). With QUADAS-2, only three of 47 studies (6.4%) had a low risk of bias in all domains (patient selection, index test, reference standard and flow and timing); 37 of 47 studies (78.8%) had low concerns regarding applicability. Studies investigated TEG®/ROTEM® for diagnosis of early coagulopathies (n = 40) or for associations with blood-product transfusion (n = 25) or mortality (n = 24). Most (n = 52) were single-center studies. Techniques examined included rapid TEG® (n =12), ROTEM® (n = 18), TEG® (n = 23), or both TEG® and rapid TEG® (n = 2). Many TEG®/ROTEM® measurements were associated with early coagulopathies, including some (hypercoagulability, hyperfibrinolysis, platelet dysfunction) not assessed by routine screening coagulation tests. Standard measures of diagnostic accuracy were inconsistently reported. Many abnormalities predicted the need for massive transfusion and death, but predictive performance was not consistently superior to routine tests. One observational study suggested that a ROTEM®-based transfusion algorithm reduced blood-product transfusion, but TEG®/ROTEM®-based resuscitation was not associated with lower mortality in most studies. CONCLUSIONS: Limited evidence from observational data suggest that TEG®/ROTEM® tests diagnose early trauma coagulopathy and may predict blood-product transfusion and mortality in trauma. Effects on blood-product transfusion, mortality, and other patient-important outcomes remain unproven in randomized trials.

Thrombelastography (TEG®): practical considerations on its clinical use in trauma resuscitation.

BACKGROUND: Thrombelastography is a laboratorial test that measures viscoelastic changes of the entire clotting process. There is growing interest in its clinical use in trauma resuscitation, particularly for managing acute coagulopathy of trauma and assisting decision making concerning transfusion. This review focuses on the clinical use of thrombelastography in trauma, with practical points to consider on its use in civilian and military settings. METHODS: A search in the literature using the terms "thrombelastography AND trauma" was performed in PUBMED database. We focused the review on the main clinical aspects of this viscoelastic method in diagnosing and treating patients with acute coagulopathy of trauma during initial resuscitation. RESULTS: Thrombelastography is not a substitute for conventional laboratorial tests such as INR and aPTT but offers additional information and may guide blood transfusion. Thrombelastography can be used as a point of care test but requires multiple daily calibrations, should be performed by trained personnel and its technique requires standardization. While useful partial results may be available in minutes, the whole test may take as long as other conventional tests. The most important data provided by thrombelastography are clot strength and fibrinolysis. Clot strength measure can establish whether the bleeding is due to coagulopathy or not, and is the key information in thrombelastography-based transfusion algorithms. Thrombelastography is among the few tests that diagnose and quantify fibrinolysis and thus guide the use of anti-fibrinolytic drugs and blood products such as cryoprecipitate and fibrinogen concentrate. It may also diagnose platelet dysfunction and hypercoagulability and potentially prevent inappropriate transfusions of hemostatic blood products to non-coagulopathic patients. CONCLUSIONS: Thrombelastography has characteristics of an ideal coagulation test for use in early trauma resuscitation. It has limitations, but may prove useful as an additional test. Future studies should evaluate its potential to guide blood transfusion and the understanding of the mechanisms of trauma coagulopathy.