Infection and Antibiotic Agents in Bleeding Trauma Patients: A Review of Available Literature.

Background: Antibiotic prophylaxis is a common, established practice at trauma centers worldwide for patients presenting with various forms of serious injury. Many patients simultaneously present with hemorrhage. The current guidelines by the Eastern Association for the Surgery of Trauma recommend re-dosing prophylactic antibiotic agents for every 10 units of blood products administered. However, these guidelines are only mildly supported by dated research. Methods: A literature search was completed through Medline EBSCO Host using antibiotic prophylaxis and transfusion as keywords. Articles judged to be relevant to the study question were selected for full-text review. Case studies were not included. Altogether, 18 articles were cited in our results through this process. Results: Risk of infection increases in patients resuscitated with large volume of blood products. Animal models of trauma offered conflicting findings on whether blood loss and blood resuscitation altered tissue antibiotic concentrations compared with controls. Studies focused on antibiotic pharmacokinetics in non-trauma human patients revealed agreement surrounding reported decreases in serum and tissue concentrations, although there was discrepancy surrounding the clinical relevancy of the reported decreases. Conclusions: Trauma, hemorrhage, and transfusion impair the immune response resulting in increased incidence of infection. Both animal and human models of antibiotic pharmacokinetics show decreased serum and tissue concentrations during hemorrhage. However, available data are insufficient to conclude that trauma patients experiencing hemorrhage are at elevated risk of infection and thus require more frequent redosing of antibiotic agents than the current guidelines suggest. An upcoming, prospective study by our institution seeks to evaluate this question.

Tactics for hemorrhagic shock: A virtual course and visual aid for improved resuscitation.

BACKGROUND: Our trauma performance improvement initiative recognized missed treatment opportunities for patients undergoing massive transfusion. To improve patient care, we developed a novel cognitive aid in the form of a poster entitled "TACTICS for Hemorrhagic Shock." We hypothesized that this reference and corresponding course would improve the performance of trauma leaders caring for simulated patients requiring massive transfusion. METHODS: First, residents and physician assistants participated in a one-on-one, socially distanced, screen-based virtual patient simulation. Next, they watched a short presentation introducing the TACTICS visual aid. They then underwent a similar second virtual simulation during which they had access to the reference. In both simulations, the participants were assessed using a scoring system developed to measure their ability to provide appropriate predetermined interventions while leading a trauma resuscitation (score range, 0-100%). Preintervention and postintervention scores were compared using a one-group pre-post within-subject design. Participants' feedback was obtained anonymously. RESULTS: Thirty-two participants (21 residents and 11 physician assistants) completed the course. The median score for the first simulation without the use of the visual aid was 43.8% (interquartile range, 33.3.8-61.5%). Commonly missed treatments included giving tranexamic acid (success rate, 37.5%), treating hypothermia (31.3%), and reversing known anticoagulation (28.1%). All participants' performance improved using the visual aid, and the median score of the second simulation was 89.6% (interquartile range, 79.2-94.8%; p < 0.001). Ninety-two percent of survey respondents "strongly agreed" that the TACTICS visual aid would be a helpful reference during real-life trauma resuscitations. CONCLUSION: The TACTICS visual aid is a useful tool for improving the performance of the trauma leader and is now displayed in our emergency department resuscitation rooms. This performance improvement course, the associated simulations, and visual aid are easily and virtually accessible to interested trauma programs. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.