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Effect of Early Equal-Proportional Infusion of Plasma and Red Blood Cells on the Prognosis of Emergency Patients with Traumatic Hemorrhage
Fan, Y., Ye, Z., Tang, Y.
Clinical laboratory. 2023;69(7)
Abstract
BACKGROUND The goal was to study the effect of early equal-proportion transfusion on the prognosis of trauma patients with bleeding. METHODS Emergency hospital trauma patients were randomly divided into two groups, a group based on assessment of blood consumption (ABC) to assess whether need to start the massive blood transfusion patients, such as proportion of blood transfusion (fresh frozen plasma: suspended red blood cells = 1:1), and the other group using traditional methods of blood transfusion, namely according to routine blood and clotting function and hemodynamic parameters, to decide when and what blood constituents should be transfused. RESULTS The coagulation got better in the early equal-proportion transfusion group, there were significant differences of PT and APTT (p < 0.05). The amount of 24 hours RBC and plasma transfusion was decreased in the early equal-proportion transfusion group, compared to the control group (p < 0.05), the length of ICU stay was shortened, the 24-hours SOFA score was improved, and there was no significant difference in 24-hours mortality, in-hospital mortality and total length of in-hospital stay (p > 0.05). CONCLUSIONS Early transfusion can reduce the total amount of blood transfusion and shorten ICU time, but has no significant effect on mortality.
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Use of Cognitive Aids to Augment Point of Care Hemorrhage Control Skills in Laypersons
Dadario, N. B., Shleiwet, N. H., Santana Felipes, R. C., Cook, B., Cooney, J. V., Stephenson, K. M., Elsmore, M., Jafri, F. N.
Disaster medicine and public health preparedness. 2023;17:e428
Abstract
OBJECTIVE The Stop the Bleed course aims to improve bystander hemorrhage control skills and may be improved with point-of-care aids. We sought to create and examine a variety of cognitive aids to identify an optimal method to augment bystander hemorrhage control skills in an emergency scenario. METHODS Randomized trial of 346 college students. Effects of a visual or visual-audio aid on hemorrhage control skills were assessed through randomization into groups with and without prior training or familiarization with aids compared with controls. Tourniquet placement, wound packing skills, and participant comfortability were assessed during a simulated active shooter scenario. RESULTS A total of 325 (94%) participants were included in the final analyses. Participants who had attended training (odds ratio [OR], 12.67; P = 9.3 × 10(-11)), were provided a visual-audio aid (OR, 1.96; P = 0.04), and were primed on their aid (OR, 2.23; P = 0.01) were superior in tourniquet placement with less errors (P < 0.05). Using an aid did not improve wound packing scores compared with bleeding control training alone (P > 0.05). Aid use improved comfortability and likelihood to intervene emergency hemorrhage scenarios (P < 0.05). CONCLUSIONS Using cognitive aids can improve bystander hemorrhage control skills with the strongest effects if they were previously trained and used an aid which combined visual and audio feedback that they were previously introduced to during the course training.
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Thrombelastography (TEG(®) 6s) early amplitudes predict maximum amplitude in severely injured trauma patients
Vigstedt M, Baksaas-Aasen K, Henriksen HH, Maegele M, Stanworth S, Juffermans NP, Kolstadbråten KM, Naess PA, Brohi K, Gaarder C, et al
Scandinavian journal of clinical and laboratory investigation. 2022;:1-5
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Editor's Choice
Abstract
Severely injured trauma patients are often coagulopathic and early hemostatic resuscitation is essential. Previous studies have revealed linear relationships between thrombelastography (TEG(®)) five- and ten-min amplitudes (A5 and A10), and maximum amplitude (MA), using TEG(®) 5000 technology. We aimed to investigate the performance of A5 and A10 in predicting low MA in severely injured trauma patients and identify optimal cut-off values for hemostatic intervention based on early amplitudes, using the cartridge-based TEG(®) 6s technology. Adult trauma patients with hemorrhagic shock were included in the iTACTIC randomized controlled trial at six European Level I trauma centers between 2016 and 2018. After admission, patients were randomized to hemostatic therapy guided by conventional coagulation tests (CCT) or viscoelastic hemostatic assays (VHA). Patients with available admission-TEG(®) 6s data were included in the analysis, regardless of treatment allocation. Low MA was defined as <55 mm for Kaolin TEG(®) and RapidTEG(®), and <17 mm for TEG(®) functional fibrinogen (FF). One hundred eighty-seven patients were included. Median time to MA was 20 (Kaolin TEG(®)), 21 (RapidTEG(®)) and 12 (TEG(®) FF) min. For Kaolin TEG(®), the optimal Youden index (YI) was at A5 < 36 mm (100/93% sensitivity/specificity) and A10 < 47 mm (100/96% sensitivity/specificity). RapidTEG(®) optimal YI was at A5 < 34 mm (98/92% sensitivity/specificity) and A10 < 45 mm (96/95% sensitivity/specificity). TEG(®) FF optimal YI was at A5 < 12 mm (97/93% sensitivity/specificity) and A10 < 15 mm (97/99% sensitivity/specificity). In summary, we found that TEG(®) 6s early amplitudes were sensitive and specific predictors of MA in severely injured trauma patients. Intervening on early amplitudes can save valuable time in hemostatic resuscitation.
PICO Summary
Population
Adult trauma patients with haemorrhagic shock enrolled in the iTACTIC study at six European trauma centers (n= 187).
Intervention
Haemostatic therapy guided by conventional coagulation tests (CCT).
Comparison
Viscoelastic haemostatic assays (VHA).
Outcome
The study aimed to investigate the performance of A5 and A10 in predicting low maximum amplitude (MA), and to identify optimal cut-off values for haemostatic intervention based on early amplitudes, using the cartridge-based TEG® 6s technology. Patients with available admission-TEG® 6s data were included in the analysis, regardless of treatment allocation. Low MA was defined as <55 mm for Kaolin TEG® and RapidTEG®, and <17 mm for TEG® functional fibrinogen (FF). Median time to MA was 20 (Kaolin TEG®), 21 (RapidTEG®) and 12 (TEG® FF) min. For Kaolin TEG®, the optimal Youden index (YI) was at A5 < 36 mm (100/93% sensitivity/specificity) and A10 < 47 mm (100/96% sensitivity/specificity). RapidTEG® optimal YI was at A5 < 34 mm (98/92% sensitivity/specificity) and A10 < 45 mm (96/95% sensitivity/specificity). TEG® FF optimal YI was at A5 < 12 mm (97/93% sensitivity/specificity) and A10 < 15 mm (97/99% sensitivity/specificity).
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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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A randomized controlled pilot trial of video-modelling versus telementoring for improved hemorrhage control wound packing
Kirkpatrick AW, McKee JL, Tomlinson C, Donley N, Ball CG, Wachs J
American journal of surgery. 2022
Abstract
INTRODUCTION Exsanguination is the most preventable cause of death. Paradigms such as STOP THE BLEED recognize increased responsibility among the less experienced with Wound Packing (WP) being a critical skill. As even trained providers may perform poorly, we compared Video-modelling (VM), a form of behavioural modelling involving video demonstration prior to intervention against remote telementoring (RTM) involving remote real-time expert-guidance. METHODS Search and Rescue (SAR-Techs), trained in WP were asked to pack a wound on a standardized simulator randomized to RMT, VM, or control. RESULTS 24 SAR-Techs (median age 37, median 16.5 years experience) participated. Controls were consistently faster than RTM (p = 0.005) and VM (p = 0.000), with no difference between RTM and VM. However, 50% (n = 4) Controls failed to pack properly, compared to 100% success in both VM and RTM, despite all SAR-Techs feeling the task was "easy". DISCUSSION Performance of a life-saving technique was improved through either VM or RTM, suggesting that both techniques are beneficial and complementary to each other. Further work should be extended to law enforcement/lay public to examine logistical challenges.
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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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Editor's Choice
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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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.
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Perceived Stress, Personality Traits, and State of Victim's Consciousness: Impact on Tourniquet Application Time and Effectiveness
Mulet M, Vuillemin Q, Lachaux J, Trousselard M, Ferrer MH
Military medicine. 2021
Abstract
INTRODUCTION One of the main avoidable causes of combat-related injury death is extremity hemorrhage. Even with regular training, failure to properly apply a tourniquet is common. In this study, we sought to assess if rescuer's stress and personality traits, along with victim's state of consciousness, had a role to explain tourniquet application failure. MATERIALS AND METHODS Eighty-seven soldiers completed a sociodemographic and personality questionnaire (perceived stress, active altruism, mindfulness, and empathy) during a forward combat casualty care course. Then, they underwent a leg hemorrhage simulation on a randomly conscious or unconscious victim. Tourniquet application time and effectiveness (using popliteal artery Doppler) were recorded. RESULTS Tourniquet application effective rate was 37% and soldiers with higher levels of perceived stress were at greater risk of failure, especially on a conscious victim. Participants who deployed overseas and those who have undergone combat rescue training were significantly quicker to apply a tourniquet. Altruist and empathetic caregivers were slower to apply the tourniquet while mindful ones were faster. CONCLUSIONS Combat-related injuries, even simulated, not only involve the rescuer's technical skills but also their ability to deal with stressful external stimuli. Tourniquet application speed seems to be influenced by perceived stress and personality traits of the rescuers. Frequent failures justify repeated training, and one way to pursue improvement could be to develop a personalized pedagogy adapting to the needs of the students according to their current skillset but also their perceived stress and personality determinants. In the pedagogical process (planning, goal setting, teaching, and evaluating), the state of consciousness of the victim seems to be a parameter that needs to be accounted for, but further studies are required to accurately describe its influence.
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Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial
Baksaas-Aasen K, Gall LS, Stensballe J, Juffermans NP, Curry N, Maegele M, Brooks A, Rourke C, Gillespie S, Murphy J, et al
Intensive care medicine. 2020
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Editor's Choice
Abstract
PURPOSE Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine whether augmenting MHPs with Viscoelastic Haemostatic Assays (VHA) would improve outcomes compared to Conventional Coagulation Tests (CCTs). METHODS This was a multi-centre, randomized controlled trial comparing outcomes in trauma patients who received empiric MHPs, augmented by either VHA or CCT-guided interventions. Primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of massive transfusion (10 or more red cell transfusions). Secondary outcomes included 28-day mortality. Pre-specified subgroups included patients with severe traumatic brain injury (TBI). RESULTS Of 396 patients in the intention to treat analysis, 201 were allocated to VHA and 195 to CCT-guided therapy. At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%, OR 1.15, 95% CI 0.76-1.73). 28-day mortality was not different overall (VHA: 25%, CCT: 28%, OR 0.84, 95% CI 0.54-1.31), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups, there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm (OR 2.12, 95% CI 0.84-5.34). CONCLUSION There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.
PICO Summary
Population
Trauma patients from the ITACTIC trial (n= 396).
Intervention
Empiric major haemorrhage protocols (MHPs) augmented by Viscoelastic Haemostatic Assays (VHA), (n= 201).
Comparison
Interventions guided by Conventional Coagulation Tests (CCTs), (n= 195).
Outcome
At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%). 28-day mortality was not different overall (VHA: 25%, CCT: 28%), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups which included patients with severe traumatic brain injury (TBI), there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm.
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Characterizing red blood cell age exposure in massive transfusion therapy: the scalar age of blood index (SBI)
DeSantis SM, Brown DW, Jones AR, Yamal JM, Pittet JF, Patel RP, Wade CE, Holcomb JB, Wang H
Transfusion. 2019
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Abstract
BACKGROUND The mortality of trauma patients requiring massive transfusion to treat hemorrhagic shock approaches 17% at 24 hours and 26% at 30 days. The use of stored RBCs is limited to less than 42 days, so older RBCs are delivered first to rapidly bleeding trauma patients. Patients who receive a greater quantity of older RBCs may have a higher risk for mortality. METHODS AND MATERIALS Characterizing blood age exposure requires accounting for the age of each RBC unit and the quantity of transfused units. To address this challenge, a novel Scalar Age of Blood Index (SBI) that represents the relative distribution of RBCs received is introduced and applied to a secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized controlled trial (NCT01545232, https://clinicaltrials.gov/ct2/show/NCT01545232). The effect of the SBI is assessed on the primary PROPPR outcome, 24-hour and 30-day mortality. RESULTS The distributions of blood storage ages successfully maps to a parameter (SBI) that fully defines the blood age curve for each patient. SBI was a significant predictor of 24-hour and 30-day mortality in an adjusted model that had strong predictive ability (odds ratio, 1.15 [1.01-1.29], p = 0.029, C-statistic, 0.81; odds ratio, 1.14 [1.02-1.28], p = 0.019, C-statistic, 0.88, respectively). CONCLUSION SBI is a simple scalar metric of blood age that accounts for the relative distribution of RBCs among age categories. Transfusion of older RBCs is associated with 24-hour and 30-day mortality, after adjustment for total units and clinical covariates.