Extra Peritoneal Packing for Exsanguinating Pelvic Hemorrhage: Should We Do It in the Emergency Department?

BACKGROUND: Extra peritoneal packing (EPP) is a quick and highly effective method to control pelvic hemorrhage. OBJECTIVES: To determine whether EPP can be as safely and efficiently performed in the emergency department (ED) as in the operating room (OR). METHODS: Retrospective study of 29 patients who underwent EPP in the ED or OR in two trauma centers in Israel 2008-2018. RESULTS: Our study included 29 patients, 13 in the ED-EPP group and 16 in the OR-EPP group. The mean injury severity score (ISS) was 34.9 ± 11.8. Following EPP, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). A raise in the mean arterial pressure (MAP) with a median of 25 mmHg (mean 30.0 ± 27.5, P < 0.001) was documented. All patients who did not achieve hemodynamic stability after EPP had multiple sources of bleeding or fatal head injury and eventually succumbed. Patients who underwent EPP in the ED showed higher change in MAP (P = 0.0458). The overall mortality rate was 27.5% (8/29) with no difference between the OR and ED-EPP. No differences were found between ED and OR-EPP in the amount of transfused blood products, surgical site infections, and length of stay in the hospital. However, patients who underwent ED-EPP were more prone to develop deep vein thrombosis (DVT): 50% (5/10) vs. 9% (1/11) in ED and OR-EPP groups respectively (P = 0.038). CONCLUSIONS: EPP is equally effective when performed in the ED or OR with similar surgical site infection rates but higher incidence of DVT.

Systematic reviews of scores and predictors to trigger activation of massive transfusion protocols.

BACKGROUND: The use of massive transfusion protocols (MTPs) in the resuscitation of hemorrhaging trauma patients ensures rapid delivery of blood products to improve outcomes, where the decision to trigger MTPs early is important. Scores and tools to predict the need for MTP activation have been developed for use to aid with clinical judgment. We performed a systematic review to assess (1) the scores and tools available to predict MTP in trauma patients, (2) their clinical value and diagnostic accuracies, and (3) additional predictors of MTP. METHODS: MEDLINE, EMBASE, and CENTRAL were searched from inception to June 2017. All studies that utilized scores or predictors of MTP activation in adult (age, ≥18 years) trauma patients were included. Data collection for scores and tools included reported sensitivities and specificities and accuracy as defined by the area under the curve of the receiver operating characteristic. RESULTS: Forty-five articles were eligible for analysis, with 11 validated and four unvalidated scores and tools assessed. Of four scores using clinical assessment, laboratory values, and ultrasound assessment the modified Traumatic Bleeding Severity Score had the best performance. Of those scores, the Trauma Associated Severe Hemorrhage score is most well validated and has higher area under the curve of the receiver operating characteristic than the Assessment of Blood Consumption and Prince of Wales scores. Without laboratory results, the Assessment of Blood Consumption score balances accuracy with ease of use. Without ultrasound use, the Vandromme and Schreiber scores have the highest accuracy and sensitivity respectively. The Shock Index uses clinical assessment only with fair performance. Other clinical variables, laboratory values, and use of point-of-care testing results were identified predictors of MTP activation. CONCLUSION: The use of scores or tools to predict MTP need to be individualized to hospital resources and skill set to aid clinical judgment. Future studies for triggering nontrauma MTP activations are needed. LEVEL OF EVIDENCE: Systematic review, level III.

Comparison of lower limb lifting and squeeze exsanguination before tourniquet inflation during total knee arthroplasty.

BACKGROUND: During total knee arthroplasty(TKA), tourniquet is widely used by most surgeons whereas the optimal application is still controversial. With this prospective randomized controlled study, we intend to investigate the effect of lower limb lifting and squeeze exsanguination methods on clinical outcomes in a series of TKAs. METHODS: Prospectively enrolled a total of 236 TKA patients from March, 2012 to November, 2016. Of which 118 patients randomly constitute Group A with lower limb lifting exsanguination technique; and the other 118 patients comprise Group B with squeeze exsanguination method. A year's follow-up measurements were recorded in detail for analysis. RESULTS: The pre-tourniquet time of Group A was significantly shorter than that in Group B (P < 0.001). Significant difference was found on skin tension blister, 3 happened in Group A and 11 happened in Group B (P = 0.031), which resulted in a difference in total complications (P = 0.039). The VAS score was significantly lower in Group A at one and seven days postoperatively, P < 0.001 and P = 0.011, respectively. No significant differences were found regarding all other clinical outcome measurements. CONCLUSION: The lower limb lifting exsanguination is a safe and effective technique. Compared with squeeze exsanguination method, it could decrease the incidence of skin tension blister and alleviate early postoperative pain reaction, no additional risks occurred regarding other clinical outcomes. Thus, it might have the potentiality to be commonly utilized in TKA procedure. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: ChiCTR1800020471. Registered on 31 December 2018 Retrospectively registered.

Pre-hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for exsanguinating pelvic haemorrhage.

AIM: To report the initial experience and outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as an adjunct to pre-hospital resuscitation of patients with exsanguinating pelvic haemorrhage. METHODS: Descriptive case series of consecutive adult patients, treated with pre-hospital Zone III REBOA by a physician-led pre-hospital trauma service, between January 2014 and July 2018. RESULTS: REBOA was attempted in 19 trauma patients (13 successful, six failed attempts) and two non-trauma patients (both successful) with exsanguinating pelvic haemorrhage. Trauma patients were severely injured (median ISS 34, IQR: 27-43) and profoundly hypotensive (median systolic blood pressure [SBP] 57, IQR: 40-68 mmHg). REBOA significantly improved blood pressure (Pre-REBOA median SBP 57, IQR: 35-67 mmHg versus Post- REBOA SBP 114, IQR: 86-132 mmHg; Median of differences 66, 95% CI: 25-74 mmHg; P < 0.001). REBOA was associated with significantly lower risk of pre-hospital cardiac arrest (REBOA 0/13 [0%] versus no REBOA 3/6 [50%], P = 0.021) and death from exsanguination (REBOA 0/13 [0%] versus no REBOA 4/6 [67%], P = 0.004), when compared to patients with a failed attempt. Successful REBOA was associated with improved survival (REBOA 8/13 [62%] versus no REBOA 2/6 [33%]; P = 0.350). Distal arterial thrombus requiring thrombectomy was common in the REBOA group (10/13, 77%). CONCLUSION: REBOA is a feasible pre-hospital resuscitation strategy for patients with exsanguinating pelvic haemorrhage. REBOA significantly improves blood pressure and may reduce the risk of pre-hospital hypovolaemic cardiac arrest and early death due to exsanguination. Distal arterial thrombus formation is common, and should be actively managed.

An Adverse Event Analysis: Inadvertent Exsanguination Following Left Ventricular Assist Device Implantation in a Child.

Neurologic deficit subsequent to cardiac surgery remains a cause of postoperative morbidity and mortality. Although myriad risk factors for postoperative cognitive decline have been identified, their individual influence remains undefined. Although less emphasis is now placed on the heart lung machine as the major source of postoperative cognitive decline, the conduct of cardiopulmonary bypass and, in particular, the management of the bypass circuit remain key to patient safety. We present a case of inadvertent intraoperative exsanguination of a patient following open heart surgery for implantation of a left ventricular assist device. The patient suffered significant neurologic damage. However, the nature of the patient's cerebral injury indicated thromboembolism as the likely cause, rather than hypoxic-ischemic injury caused by hypoperfusion. Subsequent investigation of the incident identified several possible sources and potential causes of embolization to the brain that could not rule out the exsanguination event as a contributing factor.

Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients.

BACKGROUND: Various scoring systems have been developed to predict need for massive transfusion in traumatically injured patients. Assessments of Blood Consumption (ABC) score and Shock Index (SI) have been shown to be reliable predictors for Massive Transfusion Protocol (MTP) activation. However, no study has directly compared these two scoring systems to determine which is a better predictor for MTP activation. The primary objective was to determine whether ABC or SI better predicted the need for MTP in adult trauma patients with severe hemorrhage. METHODS: This was a retrospective cohort study which included all injured patients who were trauma activations between January 1, 2009 and December 31, 2013 at an urban Level I trauma center. Patients <18 years old or with traumatic brain injury (TBI) were excluded. ABC and SI were calculated for each patient. MTP was defined as need for >10 units PRBC transfusion within 24h of emergency department arrival. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC) were used to evaluate scoring systems' ability to predict effective MTP utilization. RESULTS: A total of 645 patients had complete data for analysis. Shock Index ≥1 had sensitivity of 67.7% (95% CI 49.5%-82.6%) and specificity of 81.3% (95% CI 78.0%-84.3%) for predicting MTP, and ABC score ≥2 had sensitivity of 47.0% (95% CI 29.8%-64.9%) and specificity of 89.8% (95% CI 87.2%-92.1%). AUROC analyses showed SI to be the strongest predictor followed by ABC score with AUROC values of 0.83 and 0.74, respectively. SI had a significantly greater sensitivity (P=0.035), but a significantly weaker specificity (P<0.001) compared to ABC score. CONCLUSION: ABC score and Shock Index can both be used to predict need for massive transfusion in trauma patients, however SI is more sensitive and requires less technical skill than ABC score.

Nondisplaced pubic ramus fracture associated with exsanguination and death.

We present a case of an elderly man who sustained non-displaced fractures through the right superior and inferior pubic rami after a fall from standing and had a tragic outcome. While minimally displaced pubic ramus fractures are typically stable and require only symptomatic treatment, there have been reports, such as this one, of low-energy pubic rami fractures resulting in massive hemorrhage. Despite aggressive resuscitation and embolization of the right obturator artery, our patient ultimately died during his hospitalization. This report highlights the need to maintain a high index of suspicion for intrapelvic bleeds even in patients with nondisplaced pubic rami fractures. Rapid recognition and treatment of intrapelvic bleeds can be lifesaving.

For the patient-Evolution in the management of vascular trauma.

There has been an evolution in the diagnosis and management of vascular trauma over the past 100 years. The primary stimulus to these changes has been the increased volume of patients with cervical, truncal, and peripheral vascular injuries during military conflicts and in civilian life. Patients with "hard" signs of a vascular injury are taken to surgery emergently with a few exceptions to be described. In contrast, patients with "soft" signs of a vascular injury undergo a careful physical examination including measurement of vascular index to determine if radiologic imaging is necessary. Computed tomography arteriography has become the most commonly used method of imaging, whereas duplex ultrasonography is used in some centers. Nonoperative management is now common for nonocclusive injuries diagnosed on computed tomography arteriography. Proximal tourniquets are commonly used to control exsanguinating hemorrhage from injuries to extremities, whereas balloons can be used to control hemorrhage from difficult to expose areas at operation. Temporary intraluminal shunts are now used in 3% to 9% of arterial injuries. Operative techniques of repair have been refined and contribute to the excellent results noted in modern trauma centers.

Complications of intravenous catheterization in horses.

INTRODUCTION: Intravenous catheterization is a necessity for continuous administration of intravenous fluids and for intermittent intravenous access to avoid discomfort and potential complications of repeated needle insertions into the vein. Intravenous catheterization is commonly performed and well tolerated in horses, but catheter associated complications have been reported. The most commonly reported complication is thrombophlebitis, but others such as venous air embolism, exsanguination and catheter fragmentation may also occur. This article aims to review clinical signs, pathogenesis, diagnosis, therapy, risk factors and prevention of common catheter associated complications.

INTRODUCTION: Le cathétérisme veineux est une nécessité pour l'administration continue de fluides par voie intraveineuse et pour garantir un accès veineux intermittent afin d'éviter l'inconfort et les complications potentielles liées à la pénétration répétée d'une aiguille dans la veine. Le cathétérisme veineux est usuellement pratiqué chez le cheval et il est bien toléré mais des complications associées sont rapportées. La plus commune d'entre elle est la thrombophlébite mais d'autre, telles l'embolie gazeuse, l'exsanguination ou la fragmentation du cathéter peuvent aussi survenir. Cet article vise à résumer les signes cliniques, la pathogénèse, le diagnostic, le traitement les facteurs de risque et la prévention des complications communément associées avec le cathétérisme.

REBOA for the IVC? Resuscitative balloon occlusion of the inferior vena cava (REBOVC) to abate massive hemorrhage in retrohepatic vena cava injuries.

BACKGROUND: The use of resuscitative endovascular balloon occlusion as a maneuver for occlusion of the aorta is well described. This technique has life-saving potential in other cases of traumatic hemorrhage. Retrohepatic inferior vena cava (IVC) injuries have a high rate of mortality, in part, due to the difficulty in achieving total vascular isolation. The purpose of this study was to investigate the ability of resuscitative balloon occlusion of the IVC to control suprahepatic IVC hemorrhage in a swine model of trauma. METHODS: Thirteen swine were randomly assigned to control (seven animals) versus intervention (six animals). In both groups, an injury was created to the IVC. Hepatic inflow control was obtained via clamping of the hepatoduodenal ligament and infrahepatic IVC. In the intervention group, suprahepatic IVC control was obtained via a resuscitative balloon occlusion of the IVC placed through the femoral vein. In the control group, no suprahepatic IVC control was established. Vital signs, arterial blood gases, and lactate were monitored until death. Primary end points were blood loss and time to death. Lactate, pH, and vital signs were secondary end points. Groups were compared using the χ and the Student t test with significance at p < 0.05. RESULTS: Intervention group's time to death was significantly prolonged: 59.3 ± 1.6 versus 33.4 ± 12.0 minutes (p = 0.001); and total blood loss was significantly reduced: 333 ± 122 vs 1,701 ± 358 mL (p = 0.001). In the intervention group, five of the six swine (83.3%) were alive at 1 hour compared to zero of seven (0%) in the control group (p = 0.002). There was a trend toward worsening acidosis, hypothermia, elevated lactate, and hemodynamic instability in the control group. CONCLUSIONS: Resuscitative balloon occlusion of the IVC demonstrates superior hemorrhage control and prolonged time to death in a swine model of liver hemorrhage. This technique may be considered as an adjunct to total hepatic vascular isolation in severe liver hemorrhage and could provide additional time needed for definitive repair. LEVEL OF EVIDENCE: Therapeutic study, level II.

Early identification of patients requiring massive transfusion, embolization, or hemostatic surgery for traumatic hemorrhage: a systematic review protocol.

BACKGROUND: Hemorrhage is a major cause of early mortality following a traumatic injury. The progression and consequences of significant blood loss occur quickly as death from hemorrhagic shock or exsanguination often occurs within the first few hours. The mainstay of treatment therefore involves early identification of patients at risk for hemorrhagic shock in order to provide blood products and control of the bleeding source if necessary. The intended scope of this review is to identify and assess combinations of predictors informing therapeutic decision-making for clinicians during the initial trauma assessment. The primary objective of this systematic review is to identify and critically assess any existing multivariable models predicting significant traumatic hemorrhage that requires intervention, defined as a composite outcome comprising massive transfusion, surgery for hemostasis, or angiography with embolization for the purpose of external validation or updating in other study populations. If no suitable existing multivariable models are identified, the secondary objective is to identify candidate predictors to inform the development of a new prediction rule. METHODS: We will search the EMBASE and MEDLINE databases for all randomized controlled trials and prospective and retrospective cohort studies developing or validating predictors of intervention for traumatic hemorrhage in adult patients 16 years of age or older. Eligible predictors must be available to the clinician during the first hour of trauma resuscitation and may be clinical, lab-based, or imaging-based. Outcomes of interest include the need for surgical intervention, angiographic embolization, or massive transfusion within the first 24 h. Data extraction will be performed independently by two reviewers. Items for extraction will be based on the CHARMS checklist. We will evaluate any existing models for relevance, quality, and the potential for external validation and updating in other populations. Relevance will be described in terms of appropriateness of outcomes and predictors. Quality criteria will include variable selection strategies, adequacy of sample size, handling of missing data, validation techniques, and measures of model performance. DISCUSSION: This systematic review will describe the availability of multivariable prediction models and summarize evidence regarding predictors that can be used to identify the need for intervention in patients with traumatic hemorrhage. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017054589.

A single blind randomised controlled trial of the impact on patient-reported pain of arm elevation versus exsanguination prior to tourniquet inflation.

AIMS: The aim of this study was to compare the pain caused by the application of a tourniquet after exsanguination of the upper limb with that occurring after simple elevation. PATIENTS AND METHODS: We used 26 healthy volunteers (52 arms), each of whom acted as their own matched control. The primary outcome measure was the total pain experienced by each volunteer while the tourniquet was inflated for 20 minutes. This was calculated as the area under the pain curve for each individual subject. Secondary outcomes were pain at each time point; the total pain experienced during the recovery phase; the ability to tolerate the tourniquet and the time for full recovery after deflation of the tourniquet. RESULTS: There was a significant difference in the area under the pain curves in favour of exsanguination (mean difference 8.4; 95% confidence interval (CI) 3.0 to 13.7, p = 0.004). There was no difference between the dominant and non-dominant arms (mean difference -0.2; 95% CI -23.2 to 22.8, p = 0.99). The area under both recovery curves were similar (mean difference 0.7; 95% CI -6.0 to 4.6, p = 0.78). There was no statistical difference in recovery time, the actual mean difference being 30 seconds longer in the elevation group (p = 0.06). CONCLUSION: Many orthopaedic and plastic surgery procedures are done under local anaesthetic or regional block where a bloodless field and a motionless patient are essential. Optimising patient comfort during surgery with the tourniquet inflated is thus a priority. This study is useful in that it compares two common methods of preparation of the upper limb prior to tourniquet inflation and which have not previously been compared in this context. Following on the results of this study, we can confidently conclude that exsanguinating the upper limb before inflating a tourniquet is more comfortable than simply elevating the arm for patients undergoing a procedure under local or regional block, both during the procedure and in the recovery phase. TAKE HOME MESSAGE: Exsanguination rather than elevation is recommended in order to minimise patient discomfort and optimise the surgical field.

Mechanism of action of tranexamic acid in bleeding trauma patients: an exploratory analysis of data from the CRASH-2 trial.

INTRODUCTION: To investigate the mechanism of action of tranexamic acid (TXA) in bleeding trauma patients, we examined the timing of its effect on mortality. We hypothesised that if TXA reduces mortality by decreasing blood loss, its effect should be greatest on the day of the injury when bleeding is most profuse. However, if TXA reduces mortality via an anti-inflammatory mechanism its effect should be greater over the subsequent days. METHODS: Exploratory analysis, including per-protocol analyses, of data from the CRASH-2 trial, a randomised placebo controlled trial of the effect of TXA on mortality in 20,211 trauma patients with, or at risk of, significant bleeding. We examined hazard ratios (HR) and 95% confidence intervals for all-cause mortality, deaths due to bleeding and non-bleeding deaths, according to the day since injury. The CRASH-2 trial is registered as ISRCTN86750102 and ClinicalTrials.gov NCT00375258. RESULTS: The effect of TXA on mortality is greatest for deaths occurring on the day of the injury (HR all-cause mortality = 0.83, 0.73 to 0.93). This survival benefit is only evident in patients in whom treatment is initiated within 3 hours of their injury (HR ≤ 3 hours = 0.78, 0.68 to 0.90; HR > 3 hours = 1.02, 0.76 to 1.36). Initiation of TXA treatment within 3 hours of injury reduced the hazard of death due to bleeding on the day of the injury by 28% (HR = 0.72, 0.60 to 0.86). TXA treatment initiated beyond 3 hours of injury appeared to increase the hazard of death due to bleeding, although the estimates were imprecise. CONCLUSIONS: Early administration of tranexamic acid appears to reduce mortality primarily by preventing exsanguination on the day of the injury.

IV access in bleeding trauma patients: a performance review.

BACKGROUND: Exsanguinating haemorrhage is a leading cause of death in severely injured trauma patients. Management includes achieving haemostasis, replacing lost intravascular volume with fluids and blood, and treating coagulopathy. The provision of fluids and blood products is contingent on obtaining adequate vascular access to the patient's venous system. We sought to examine the nature and timing of achieving adequate intravenous (IV) access in trauma patients requiring uncrossmatched blood in the trauma bay. METHODS: We performed a retrospective chart review of all patients admitted to our trauma centre from 2005 to 2009 who were transfused uncrossmatched blood in the trauma bay. We examined the impact of IV access on prehospital times and time to first PRBC transfusion. RESULTS: Of 208 study patients, 168 (81%) received prehospital IV access, and the on-scene time for these patients was 5 min longer (16.1 vs 11.4, p<0.01). Time to achieving adequate IV access in those without any prehospital IVs occurred on average 21 min (6.6-30.5) after arrival to the trauma bay. A central venous catheter was placed in 92 (44%) of patients. Time to first blood transfusion correlated most strongly with time to achieving central venous access (Pearson correlation coefficient 0.94, p<0.001) as opposed to time to achieving adequate peripheral IV access (Pearson correlation coefficient 0.19, p=0.12). CONCLUSIONS: We found that most bleeding patients received a prehospital IV; however, we also found that obtaining prehospital IVs was associated with longer EMS on-scene times and longer prehospital times. Interestingly, we found that obtaining a prehospital IV was not associated with more rapid initiation of blood product transfusion. Obtaining optimal IV access and subsequent blood transfusion in severely injured patients continues to present a challenge.

The STOP the Bleeding Campaign.

According to the World Health Organization, traumatic injuries worldwide are responsible for over 5 million deaths annually. Post-traumatic bleeding caused by traumatic injury-associated coagulopathy is the leading cause of potentially preventable death among trauma patients. Despite these facts, awareness of this problem is insufficient and treatment options are often unclear. The STOP the Bleeding Campaign therefore aims to increase awareness of the phenomenon of post-traumatic coagulopathy and its appropriate management by publishing European guidelines for the management of the bleeding trauma patient, by promoting and monitoring the implementation of these guidelines and by preparing promotional and educational material, organising activities and developing health quality management tools. The campaign aims to reduce the number of patients who die within 24 hours after arrival in the hospital due to exsanguination by a minimum of 20% within the next 5 years.