1.
Errors in adult trauma resuscitation: a systematic review
Nikouline A, Quirion A, Jung JJ, Nolan B
Cjem. 2021
Abstract
INTRODUCTION Trauma resuscitation at dedicated trauma centers typically consist of ad-hoc teams performing critical tasks in a time-limited manner. This creates a high stakes environment apt or avoidable errors. Reporting of errors in trauma resuscitation is generally center-dependent and lacks common terminology. METHODS We conducted a systematic review by searching Ovid Medline, Scopus and Embase from inception to February 24, 2021 for errors in adult trauma resuscitation. English studies published after 2001 were included. Studies were assessed by two independent reviewers for meeting inclusion/exclusion criteria. Errors were characterized from the included studies and a summary table was developed. Our review was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020152875). RESULTS The literature search retrieved 4658 articles with 26 meeting eligibility criteria. Errors were identified by morbidity and mortality rounds or other committee in 62%, missed injuries on tertiary assessment or radiology review in 12%, deviations from algorithmic guidelines in 12% or predefined for chest tube complications, critical incident reporting, aspiration or delays in care. In total there were 39 unique error types identified and divided into 9 categories including Emergency Medical Services handover, airway, assessment of injuries, patient monitoring and access, transfusion/blood related, management of injuries, team communication/dynamics, procedure error and disposition. CONCLUSIONS Overall, our systematic review identified 39 unique error types in trauma resuscitation. Identifying these errors is imperative in developing systems for improvement of trauma care.
2.
The impact of blood product ratio and procoagulant therapy on the development of thromboembolic events in severely injured hemorrhaging trauma patients
Wirtz MR, Schalkers DV, Goslings JC, Juffermans NP
Transfusion. 2020
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Editor's Choice
Abstract
INTRODUCTION Transfusion therapy in hemorrhaging trauma patients is associated with the development of thromboembolic events. It is unknown whether current resuscitation strategies, including large volumes of plasma and early administration of procoagulant therapy, increases this risk. METHODS A systematic search was conducted in MEDLINE, PubMed, and Embase. Studies were screened by two independent reviewers and included if they reported on thromboembolic events in patients with severe trauma (injury severity score ≥16) who received transfusion of at least 1 unit of red blood cells. The ratio by which blood products were transfused, as well as use of procoagulant or antifibrinolytic medication, was recorded. RESULTS A total of 40 studies with 11.074 bleeding trauma patients were included, in which 1.145 thromboembolic events were reported, yielding an incidence of 10% thromboembolic events. In studies performing routine screening for thromboembolic complications, the incidence ranged from 12% to 23%. The risk of thromboembolic events was increased after administration of tranexamic acid (TXA; odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7-4.1; p < 0.001) and fibrinogen concentrate (OR, 2.1; 95% CI, 1.0-4.2; p = 0.04). Blood product ratio, the use of prothrombin complex concentrate or recombinant factor VIIa were not associated with thromboembolic events. CONCLUSION This systematic review identified an incidence of thromboembolic events of 10% in severely injured bleeding trauma patients. The use of TXA and fibrinogen concentrate was associated with the development of thromboembolic complications.
PICO Summary
Population
Patients with severe trauma who received transfusion of at least 1 unit of red blood cells (40 studies, n= 11074).
Intervention
Systematic review on the incidence of thromboembolic events.
Comparison
Outcome
A total of 1145 thromboembolic events were reported, yielding an incidence of 10% thromboembolic events. In studies performing routine screening for thromboembolic complications, the incidence ranged from 12% to 23%. The risk of thromboembolic events was increased after administration of tranexamic acid and fibrinogen concentrate. Blood product ratio, the use of prothrombin complex concentrate or recombinant factor VIIa were not associated with thromboembolic events.
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Risk factors for trauma-induced coagulopathy and transfusion-associated multiple organ failure in severely injured trauma patients
Balvers K, Wirtz MR, van Dieren S, Goslings JC, Juffermans NP
Frontiers in Medicine. 2015;2:24
Abstract
BACKGROUND Both trauma-induced coagulopathy (TIC) and transfusion strategies influence early outcome in hemorrhagic trauma patients. Their impact on late outcome is less well characterized. This study systematically reviews risk factors for TIC- and transfusion-associated multiple organ failure (MOF) in severely injured trauma patients. MATERIALS AND METHODS A systematic search was conducted in PubMed and Embase. Studies published from 1986 to 2013 on adult trauma patients with an injury severity score >16, investigating TIC or transfusion strategies with MOF as primary or secondary outcome, were eligible for inclusion. Results of the included studies were evaluated with meta-analyses of pooled data. RESULTS In total, 50 studies were included with a total sample size of 63,586 patients. Due to heterogeneity of the study populations and outcome measures, results from 7 studies allowed for pooling of data. Risk factors for TIC-associated MOF were hypocoagulopathy, hemorrhagic shock, activated protein C, increased histone levels, and increased levels of markers of fibrinolysis on admission. After at least 24h after admission, the occurrence of thromboembolic events was associated with MOF. Risk factors for transfusion-associated MOF were the administration of fluids and red blood cell units within 24h post-injury, the age of red blood cells (>14days) and a ratio of FFP:RBC>1:1 (OR 1.11, 95% CI 1.04-1.19). CONCLUSION Risk factors for TIC-associated MOF in severely injured trauma patients are early hypocoagulopathy and hemorrhagic shock, while a hypercoagulable state with the occurrence of thromboembolic events later in the course of trauma predisposes to MOF. Risk factors for transfusion-associated MOF include administration of crystalloids and red blood cells and a prolonged storage time of red blood cells. Future prospective studies investigating TIC- and transfusion-associated risk factors on late outcome are required.
