Association of red blood cells and plasma transfusion versus red blood cell transfusion only with survival for treatment of major traumatic hemorrhage in prehospital setting in England: a multicenter study.

BACKGROUND: In-hospital acute resuscitation in trauma has evolved toward early and balanced transfusion resuscitation with red blood cells (RBC) and plasma being transfused in equal ratios. Being able to deliver this ratio in prehospital environments is a challenge. A combined component, like leukocyte-depleted red cell and plasma (RCP), could facilitate early prehospital resuscitation with RBC and plasma, while at the same time improving logistics for the team. However, there is limited evidence on the clinical benefits of RCP. OBJECTIVE: To compare prehospital transfusion of combined RCP versus RBC alone or RBC and plasma separately (RBC + P) on mortality in trauma bleeding patients. METHODS: Data were collected prospectively on patients who received prehospital transfusion (RBC + thawed plasma/Lyoplas or RCP) for traumatic hemorrhage from six prehospital services in England (2018-2020). Retrospective data on patients who transfused RBC from 2015 to 2018 were included for comparison. The association between transfusion arms and 24-h and 30-day mortality, adjusting for age, injury mechanism, age, prehospital heart rate and blood pressure, was evaluated using generalized estimating equations. RESULTS: Out of 970 recruited patients, 909 fulfilled the study criteria (RBC + P = 391, RCP = 295, RBC = 223). RBC + P patients were older (mean age 42 vs 35 years for RCP and RBC), and 80% had a blunt injury (RCP = 52%, RBC = 56%). RCP and RBC + P were associated with lower odds of death at 24-h, compared to RBC alone (adjusted odds ratio [aOR] 0.69 [95%CI: 0.52; 0.92] and 0.60 [95%CI: 0.32; 1.13], respectively). The lower odds of death for RBC + P and RCP vs RBC were driven by penetrating injury (aOR 0.22 [95%CI: 0.10; 0.53] and 0.39 [95%CI: 0.20; 0.76], respectively). There was no association between RCP or RBC + P with 30-day survival vs RBC. CONCLUSION: Prehospital plasma transfusion for penetrating injury was associated with lower odds of death at 24-h compared to RBC alone. Large trials are needed to confirm these findings.

Evaluating Services at a Major Trauma Center Before Helipad Construction.

INTRODUCTION: Two of the 4 hospitals designated as major trauma centers in London, UK, currently operate on-site helicopter landing pads. King's College Hospital (KCH) is constructing a third. We evaluate current trauma services at King's College Hospital, before the helipad entering service, establishing baseline workload and mortality measures. METHODS: We retrospectively analyzed data from patients admitted January 1, 2014, to December 31, 2015, to KCH after major trauma with on-scene helicopter emergency medical services involvement (N = 427) using the Trauma Audit and Research Network database. RESULTS: The median Injury Severity Score of the cohort was 22 (interquartile range [IQR], 13-30). The median length of stay was 11 days (IQR, 5-24). Fifty-seven percent of the patients received intensive care unit (ICU) admission, with a median ICU length of stay (LOS) of 5 days (IQR, 2-12) in this subgroup. There was no significant difference in Injury Severity Score, LOS, or ICU LOS between 2014 and 2015. One hundred ninety-three patients (45.2%) underwent ≥ 1 operation, accounting for 1,276.5 hours of operating room time in total. Cox proportional hazards regression showed no difference in survival outcomes between 2014 and 2015. CONCLUSION: Baseline workload and mortality measures were obtained, forming the basis of future service evaluation to assess the impact of helipad construction.

Improving documentation in prehospital rapid sequence intubation: investigating the use of a dedicated airway registry form.

OBJECTIVE: The quality of medical documentation is integral to audit, clinical governance, education, medico-legal aspects and continuity of patient care. This study aims to investigate the introduction of a dedicated 'Airway Registry Form' (ARF) on the quality of documentation in prehospital rapid sequence intubation. METHODS: A retrospective review and comparison of 96 cases predating the introduction of the ARF and 90 cases immediately following its introduction were performed. RESULTS: The introduction of the ARF yielded significant improvement in the recording of selected data points: difficult airway indicators (p<0.0001), Cormack-Lehane grade of laryngoscopy at first attempt (p<0.0001), documentation of confirmation of tracheal intubation with end-tidal carbon dioxide monitoring (p=0.015) and recording of intubator's details (p<0.0001). CONCLUSIONS: This study validates the use of a dedicated ARF for the improvement of documentation and data collection related to prehospital rapid sequence intubation when compared with post-event extraction of data from a generic case-record.

The stove-in chest: a complex flail chest injury.

The stove-in chest is a rare form of flail chest in which there is collapse of a segment of the chest wall, associated with a high immediate mortality. A 65-year-old male pedestrian was admitted with severe chest pain and dyspnoea, after being struck by a car. The initial chest radiograph demonstrated multiple right-sided rib fractures and pulmonary contusion. His gas exchange was good, and after pain relief via an epidural catheter was achieved, an intercostal drain was inserted into the right hemi-thorax. Clinically apparent deformation of the chest then occurred. A further chest radiograph confirmed the stove-in chest. The patient remained well initially, but on day 5 he deteriorated precipitously with respiratory failure, and signs of systemic sepsis. He died despite maximal ventilatory and inotropic support on the Intensive Care Unit (ICU). Post-mortem examination demonstrated congested, oedematous lungs with a right-sided empyema. The management of complex flail chest injuries requires treatment to be tailored to the individual patient. Early ventilatory support, despite good gas exchange, may have closed down the pleural space prevented the empyema. Prophylactic ventilation and possibly surgical stabilisation of the chest wall should be considered early in the course of admission, even when the conventional parameters to indicate ventilation are not met.