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A systematic review of indications when and how a military walking Blood Bank could bridge blood product unavailability
Degueldre, J., Dessy, E., T'Sas, F., Deneys, V.
Blood transfusion = Trasfusione del sangue. 2024
Abstract
BACKGROUND Blood supply problems in remote areas are well known. To overcome this shortage, many countries have developed innovative Walking Blood Bank (WBB) protocols. However, no common standards have yet been set for their use and common actions. Given that these procedures involve a certain risk, it would be interesting to analyse the activating criteria that lead to using this unusual protocol. Thus, this review aimed to identify indications for a WBB and the common risk mitigation measures. MATERIAL AND METHODS This PRISMA-compliant review only included studies published from 1985 to 25(th) of January 2023 that describe adult male military casualties requiring blood transfused locally using a walking blood transfusion protocol. All relevant data (i.e., activation and contextual factors and risk mitigation measures) were tabulated to retrieve information from the selected military studies. RESULTS Our results indicated that activation criteria were homogeneous across the 12 reviewed studies. Whole blood was collected from a WBB when there was a shortage of blood products and when platelets were needed. In the literature reviewed, the main risks associated with such a protocol, namely hemolytic adverse events and transfusion transmitted diseases, are mitigated by the use of typing and screening measures if they are reported. However, there is less consistency in the implementation of those risk mitigation measures. DISCUSSION This unusual protocol needs to be integrated into the medical support plan until conventional transfusion support can take over, and should include on-site blood collection from a donor, whether a WBB or an emergency donor panel. The benefits of such a protocol outweigh the risks in a life-threatening situation, especially since these risks can be anticipated and minimised by planning to pre-screen all potential donors before their deployment. Finally, educating and training the staff who must implement this unusual procedure can also improve the safety and survival rate of future patients.
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Detection of Acute Traumatic Coagulopathy by Viscoelastic Haemostatic Assays Compared to Standard Laboratory Tests: A Systematic Review
Forster, E. K., Hendel, S., Mitra, B.
Transfusion medicine and hemotherapy : offizielles Organ der Deutschen Gesellschaft fur Transfusionsmedizin und Immunhamatologie. 2023;50(4):334-347
Abstract
INTRODUCTION The aim of this systematic review was to investigate whether viscoelastic haemostatic assays (VHAs) offer comparative diagnostic ability of acute traumatic coagulopathy (ATC) compared to the standard laboratory coagulation tests (SLCT). ATC is a complication of major trauma characterized by dysfunctional blood clotting, leading to an increased bleeding risk. Additionally, we aimed to analyse the association of VHA with blood product use and health outcomes. METHODS The search protocol was pre-published and completed on December 2, 2020, assessing manuscripts from 2000 until the present. We searched MEDLINE, Embase, Cochrane Central, BIOSIS, Emcare, CINAHL, and additional online resources and referenced lists. Included were manuscripts that quantitatively reported the detection of ATC using VHAs and SLCTs. A meta-analysis was undertaken including observational studies that reported on patients with injuries to all body regions and results analysed using a random-effects model and reported using pooled odds ratio with 95% confidence intervals (CI). RESULTS There were 14 observational studies and one randomized control trial involving 2,715 participants that satisfied inclusion criteria. We observed significant heterogeneity in the definitions of ATC, study design, setting, and patient population. Among observational studies that reported on patients with injuries to all body regions, VHAs were associated with higher odds of diagnosing ATC compared to SLCT (pooled OR 2.4; 95% CI: 1.4-4.1). There was inadequate evidence to suggest VHAs were associated with reduced blood product usage or lower mortality. CONCLUSION VHAs detected more patients with ATC compared to SLCTs. However, the clinical significance and applicability of this finding remains unknown as translation to management was not adequately reported.
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Predictive value of tachycardia for mortality in trauma-related haemorrhagic shock: a systematic review and meta-regression
Jávor, P., Hanák, L., Hegyi, P., Csonka, E., Butt, E., Horváth, T., Góg, I., Lukacs, A., Soós, A., Rumbus, Z., et al
BMJ open. 2022;12(10):e059271
Abstract
OBJECTIVES Heart rate (HR) is one of the physiological variables in the early assessment of trauma-related haemorrhagic shock, according to Advanced Trauma Life Support (ATLS). However, its efficiency as predictor of mortality is contradicted by several studies. Furthermore, the linear association between HR and the severity of shock and blood loss presented by ATLS is doubtful. This systematic review aims to update current knowledge on the role of HR in the initial haemodynamic assessment of patients who had a trauma. DESIGN This study is a systematic review and meta-regression that follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. DATA SOURCES EMBASE, MEDLINE, CENTRAL and Web of Science databases were systematically searched through on 1 September 2020. ELIGIBILITY CRITERIA Papers providing early HR and mortality data on bleeding patients who had a trauma were included. Patient cohorts were considered haemorrhagic if the inclusion criteria of the studies contained transfusion and/or positive focused assessment with sonography for trauma and/or postinjury haemodynamical instability and/or abdominal gunshot injury. Studies on burns, traumatic spinal or brain injuries were excluded. Papers published before January 2010 were not considered. DATA EXTRACTION AND SYNTHESIS Data extraction and risk of bias were assessed by two independent investigators. The association between HR and mortality of patients who had a trauma was assessed using meta-regression analysis. As subgroup analysis, meta-regression was performed on patients who received blood products. RESULTS From a total of 2017 papers, 19 studies met our eligibility criteria. Our primary meta-regression did not find a significant relation (p=0.847) between HR and mortality in patients who had a trauma with haemorrhage. Our subgroup analysis included 10 studies, and it could not reveal a linear association between HR and mortality rate. CONCLUSIONS In accordance with the literature demonstrating the multiphasic response of HR to bleeding, our study presents the lack of linear association between postinjury HR and mortality. Modifying the pattern of HR derangements in the ATLS shock classification may result in a more precise teaching tool for young clinicians.
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Comparison of two teaching methods for stopping the bleed: a randomized controlled trial
Chen, S., Li, J., DiNenna, M. A., Gao, C., Chen, S., Wu, S., Tang, X., He, J.
BMC medical education. 2022;22(1):281
Abstract
BACKGROUND The "Stop the Bleed" (STB) campaign has achieved remarkable results since it was launched in 2016, but there is no report on the teaching of an STB course combined with a trauma patient simulator. This study proposes the "problem-, team-, and evidence-based learning" (PTEBL) teaching method combined with Caesar (a trauma patient simulator) based on the STB course and compares its effect to that of the traditional teaching method among outstanding doctoral candidates training in haemostasis skills. METHOD Seventy-eight outstanding doctoral candidate program students in five and eight-year programs were selected as the research subjects and were randomly divided into a control group (traditional teaching method, n = 34) and an experimental group (PTEBL teaching method combined with Caesar, n = 44). Their confidence in their haemostasis skills and willingness to rescue injured victims were investigated before and after the course in both groups. RESULT Students' self-confidence in their STB skills and the willingness to rescue improved after the class in both groups. Compared with the control group, students in the experimental group were more confident in compressing with bandages and compressing with a tourniquet after a class (compressing with bandages: control group 3.9 ± 0.8 vs. experimental group 4.3 ± 0.7, P = 0.014; compressing with a tourniquet: control group 3.9 ± 0.4 vs. experimental group 4.5 ± 0.8, P = 0.001) More students in the experimental group than the control group thought that the use of Caesar for scenario simulation could improve learning (control group 55.9% vs. experimental group 81.8%, P = 0.024), and using this mannequin led to higher teacher-student interaction (control group 85.3% vs. experimental group 97.7%, P = 0.042). The overall effectiveness of the teaching was better in the experimental group than in the control group (control group 85.3% vs. experimental group 97.7%, P = 0.042). There was a significant positive correlation between teacher-student interactions and the overall effectiveness of teaching (R = 1.000; 95% CI, 1.000-1.000; P < 0.001). CONCLUSION The PTEBL teaching method combined with Caesar can effectively improve student mastery of STB skills and overcome the shortcomings of traditional teaching methods, which has some promotional value in the training of outstanding doctoral candidates in STB skills.
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Hypocalcemia as a predictor of mortality and transfusion. A scoping review of hypocalcemia in trauma and hemostatic resuscitation
Kronstedt S, Roberts N, Ditzel R, Elder J, Steen A, Thompson K, Anderson J, Siegler J
Transfusion. 2022
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Abstract
BACKGROUND Calcium plays an essential role in physiologic processes, including trauma's "Lethal Diamond." Thus, inadequate serum calcium in trauma patients exacerbates the effects of hemorrhagic shock secondary to traumatic injury and subsequently poorer outcomes compared to those with adequate calcium levels. Evidence to date supports the consideration of calcium derangements when assessing the risk of mortality and the need for blood product transfusion in trauma patients. This review aims to further elucidate the predictive strength of this association for future treatment guidelines and clinical trials. METHODS Publications were collected on the relationship between i-Ca and the outcomes of traumatic injuries from PubMed, Web of Science, and CINAHL. Manuscripts were reviewed to select for English language studies. Hypocalcemia was defined as i-Ca <1.2 mmol/L. RESULTS Using PRISMA guidelines, we reviewed 300 studies, 7 of which met our inclusion criteria. Five papers showed an association between hypocalcemia and mortality. CONCLUSIONS In adult trauma patients, there has been an association seen between hypocalcemia, mortality, and the need for increased blood product transfusions. It is possible we are now seeing an association between low calcium levels prior to blood product administration and an increased risk for mortality and need for transfusion. Hypocalcemia may serve as a biomarker to show these needs. Therefore, hypocalcemia could potentially be used as an independent predictor for multiple transfusions such that ionized calcium measurements could be used predictively, allowing faster administration of blood products.
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Robotically applied hemostatic clamping for care-under-fire: harnessing bomb robots for hemorrhage control
Kirkpatrick AW, McKee IA, Knudsen B, Shelton R, LaPorta AJ, Wachs J, McKee JL
Canadian journal of surgery. Journal canadien de chirurgie. 2022;65(2):E242-e249
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Abstract
BACKGROUND Early hemorrhage control after interpersonal violence is the most urgent requirement to preserve life and is now recognized as a responsibility of law enforcement. Although earlier entry of first responders is advocated, many shooting scenes remain unsafe for humans, necessitating first responses conducted by robots. Thus, robotic hemorrhage control warrants study as a care-under-fire treatment option. METHODS Two bomb disposal robots (Wolverine and Dragon Runner) were retrofitted with hemostatic wound clamps. The robots' ability to apply a wound clamp to a simulated extremity exsanguination while controlled by 4 experienced operators was tested. The operators were randomly assigned to perform 10 trials using 1 robot each. A third surveillance robot (Stair Climber) provided further visualization for the operators. We assessed the success rate of the application of the wound clamp to the simulated wound, the time to application of the wound clamp and the amount of fluid loss. We also assessed the operators' efforts to apply the wound clamp after an initial attempt was unsuccessful or after the wound clamp was dropped. RESULTS Remote robotic application of a wound clamp was demonstrated to be feasible, with complete cessation of simulated bleeding in 60% of applications. This finding was consistent across all operators and both robots. There was no difference in the success rates with the 2 robots (p = 1.00). However, there were differences in fluid loss (p = 0.004) and application time (p < 0.001), with the larger (Wolverine) robot being faster and losing less fluid. CONCLUSION Law enforcement tactical robots were consistently able to provide partial to complete hemorrhage control in a simulated extremity exsanguination. Consideration should be given to using this approach in care-under-fire and care-behind-the-barricade scenarios as well as further developing the technology and doctrine for robotic hemorrhage control.
PICO Summary
Population
Public safety bomb technicians (n= 4).
Intervention
Application of wound clamps with the heavy-duty bomb disposal Wolverine robot (n= 2).
Comparison
Application of wound clamps with the lightweight bomb disposal Dragon Runner robot (n= 2).
Outcome
There was complete cessation of simulated bleeding in 60% of applications consistently across all technicians and both robots. There was no difference in success rates with the two robots. However, there were differences in fluid loss and application time, with the Wolverine robot being faster and losing less fluid.
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Utility of viscoelastic hemostatic assay to guide hemostatic resuscitation in trauma patients: a systematic review
Zhu, Z., Yu, Y., Hong, K., Luo, M., Ke, Y.
World Journal of Emergency Surgery : Wjes. 2022;17(1):48
Abstract
OBJECTIVE Viscoelastic hemostatic assay (VHA) provides a graphical representation of a clot's lifespan and reflects the real time of coagulation. It has been used to guide trauma resuscitation; however, evidence of the effectiveness of VHAs is still limited. This systematic review aims to summarize the published evidence to evaluate the VHA-guided strategy in resuscitating trauma patients. METHODS The PubMed, Embase, and Web of Science databases were searched from their inception to December 13, 2021. Randomized controlled trials (RCTs) or observational studies comparing VHA-guided transfusion to controls in resuscitating trauma patients were included in this systematic review. RESULTS Of the 7743 records screened, ten studies, including two RCTs and eight observational studies, met the inclusion criteria. There was great heterogeneity concerning study design, enrollment criterion, VHA device, VHA-guided strategy, and control strategy. Thrombelastography (TEG) was used as a guiding tool for transfusion in eight studies, and rotational thromboelastometry (ROTEM), and TEG or ROTEM were used in the other two studies. The overall risk of bias assessment was severe or mild in RCTs and was severe or moderate in observational studies. The main outcomes reported from the included studies were blood transfusion (n = 10), mortality (n = 10), hospital length of stay (LOS) (n = 7), intensive care unit LOS (n = 7), and cost (n = 4). The effect of the VHA-guided strategy was not always superior to the control. Most of the studies did not find significant differences in the transfusion amount of red blood cells (n = 7), plasma (n = 5), platelet (n = 7), cryoprecipitate/fibrinogen (n = 7), and mortality (n = 8) between the VHA-guided group and control group. Notable, two RCTs showed that the VHA-guided strategy was superior or equal to the conventional coagulation test-guided strategy in reducing mortality, respectively. CONCLUSION Although some studies demonstrated VHA-guided strategy probable benefit in reducing the need for blood transfusion and mortality when resuscitating trauma patients, the evidence is still not robust. The quality of evidence was primarily downgraded by the limited number of included studies and great heterogeneity and severe risk of bias in these. Further studies are strongly recommended.
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Metrics of shock in pediatric trauma patients: A systematic search and review
Alberto, E. C., McKenna, E., Amberson, M. J., Tashiro, J., Donnelly, K., Thenappan, A. A., Tempel, P. E., Ranganna, A. S., Keller, S., Marsic, I., et al
Injury. 2021;52(10):3166-3172
Abstract
INTRODUCTION Shock-index (SI) and systolic blood pressure (SBP) are metrics for identifying children and adults with hemodynamic instability following injury. The purpose of this systematic review was to assess the quality of these metrics as predictors of outcomes following pediatric injury. MATERIALS AND METHODS We conducted a literature search in Pubmed, SCOPUS, and CINAHL to identify studies describing the association between shock metrics on the morbidity and mortality of injured children and adolescents. We used the data presented in the studies to calculate the sensitivity and specificity for each metric. This study was registered with Prospero, protocol CRD42020162971. RESULTS Fifteen articles met the inclusion criteria. seven studies evaluated SI or SIPA score, an age-corrected version of SI, as predictors of outcomes following pediatric trauma, with one study comparing SIPA score and SBP and one study comparing SI and SBP. The remaining eight studies evaluated SBP as the primary indicator of shock. The median sensitivity for predicting mortality and need for blood transfusion was highest for SI, followed by SIPA, and then SBP. The median specificity for predicting these outcomes was highest for SBP, followed by SIPA, and then SI. CONCLUSIONS Common conclusions were that high SIPA scores were more specific than SI and more sensitive than SBP. SIPA score had better discrimination for severely injured children compared to SI and SBP. An elevated SIPA was associated with a greater need for blood transfusion and higher in-hospital mortality. SIPA is specific enough to exclude most patients who do not require a blood transfusion.
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Use of Thromboelastography in the Evaluation and Management of Patients With Traumatic Brain Injury: A Systematic Review and Meta-Analysis
Cannon JW, Dias JD, Kumar MA, Walsh M, Thomas SG, Cotton BA, Schuster JM, Evans SL, Schreiber MA, Adam EH, et al
Critical care explorations. 2021;3(9):e0526
Abstract
Traumatic brain injury is associated with coagulopathy that increases mortality risk. Viscoelastic hemostatic assays such as thromboelastography (Haemonetics SA, Signy, Switzerland) provide rapid coagulopathy assessment and may be particularly useful for goal-directed treatment of traumatic brain injury patients. We conducted a systematic review to assess thromboelastography in the evaluation and management of coagulopathy in traumatic brain injury patients. DATA SOURCES MEDLINE, PubMed Central, Embase, and CENTRAL. STUDY SELECTION Clinical studies of adult patients with traumatic brain injury (isolated or polytrauma) who were assessed by either standard thromboelastography or thromboelastography with platelet mapping plus either conventional coagulation assays or platelet function assays from January 1999 to June 2021. DATA EXTRACTION Demographics, injury mechanism and severity, diagnostic, laboratory data, therapies, and outcome data were extracted for analysis and comparison. DATA SYNTHESIS Database search revealed 1,169 sources; eight additional articles were identified by the authors. After review, 31 publications were used for qualitative analysis, and of these, 16 were used for quantitative analysis. Qualitative and quantitative analysis found unique patterns of thromboelastography and thromboelastography with platelet mapping parameters in traumatic brain injury patients. Patterns were distinct compared with healthy controls, nontraumatic brain injury trauma patients, and traumatic brain injury subpopulations including those with severe traumatic brain injury or penetrating traumatic brain injury. Abnormal thromboelastography K-time and adenosine diphosphate % inhibition on thromboelastography with platelet mapping are associated with decreased survival after traumatic brain injury. Subgroup meta-analysis of severe traumatic brain injury patients from two randomized controlled trials demonstrated improved survival when using a viscoelastic hemostatic assay-guided resuscitation strategy (odds ratio, 0.39; 95% CI, 0.17-0.91; p = 0.030). CONCLUSIONS Thromboelastography and thromboelastography with platelet mapping characterize coagulopathy patterns in traumatic brain injury patients. Abnormal thromboelastography profiles are associated with poor outcomes. Conversely, treatment protocols designed to normalize abnormal parameters may be associated with improved traumatic brain injury patient outcomes. Current quality of evidence in this population is low; so future efforts should evaluate viscoelastic hemostatic assay-guided hemostatic resuscitation in larger numbers of traumatic brain injury patients with specific focus on those with traumatic brain injury-associated coagulopathy.
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Effects of emergency treatment mode of damage-control orthopedics in pelvic fracture complicated with multiple fractures
Fan H, Fei R, Guo C, Li Y, Yan C, Chen F, Zhang Y
American journal of translational research. 2021;13(6):6817-6826
Abstract
OBJECTIVE This study aimed to observe the application effect of emergency treatment mode of damage-control orthopedics (DCO) in pelvic fracture complicated with multiple fractures. METHODS Ninety-four patients with pelvic fracture complicated with multiple fractures in our hospital were recruited and divided into two groups according to the random number table method, with 47 cases in each group. Patients in the control group received traditional methods for emergency treatment (early complete treatment), and patients in the research group received DCO for emergency treatment (treatment performed in stages according to patient's physiological tolerance, with simplified initial surgery, followed by ICU resuscitation, and finally definitive surgery). The two groups were compared in terms of mortality, the incidence of acidosis and hypothermia three days after the first surgery, surgery-related indexes (time of the first surgery, blood transfusion volume, intraoperative blood loss, recovery time of temperature, and length of hospital stay), coagulation function indexes (activated partial thromboplastin time (APTT), thrombin time (TT), prothrombin time (PT) and fibrinogen (FIB)), postoperative reduction of fracture, complication rate, and quality of life. RESULTS The incidences of acidosis, hypothermia, and mortality three days after the first surgery in the research group were lower than those in the control group (P<0.05). Compared with the control group, the research group experienced shorter time of the first surgery, less intraoperative blood transfusion volume, less intraoperative blood loss, shorter recovery time of body temperature, and shorter length of hospital stay (P<0.05). Seven days after surgery, PT, TT and APTT decreased and FIB increased in both groups (P<0.05), PT, TT and APTT in the research group were lower than those in the control group (P<0.05), while FIB was higher (P<0.05). The good rate of reduction in the research group was higher than that in the control group (P=0.025). The incidence of complications in the research group was lower than that in the control group (P=0.049). Six months after surgery, the scores of physiological function (PF), body pain (BP), role physical (RP), emotional function (EF), social function (SF), vitality, and general health (GH) of the research group were higher than those of the control group (P<0.05), but there was no significant difference in mental health (MH) between the two groups (P>0.05). CONCLUSION The emergency treatment mode of DCO is effective in pelvic fracture complicated with multiple fractures, which can effectively improve postoperative reduction of patients, improve the coagulation function, reduce complications, and improve the quality of life.