1.
The effectiveness of junctional tourniquets: a systematic review and meta-analysis
Smith S, White J, Wanis KN, Beckett A, McAlister VC, Hilsden R
The journal of trauma and acute care surgery. 2018
Abstract
BACKGROUND Junctional tourniquets have been incorporated into tactical combat casualty care for junctional vascular trauma. They apply external compression to stop blood flow in the groin and axilla. OBJECTIVES The primary outcome was effectiveness in achieving arterial occlusion. Secondary outcomes included time to application and pain scores. DATA SOURCES Medline and EMBASE databases were searched. STUDY APPRAISAL AND SYNTHESIS METHODS A random effects meta-analysis was conducted to estimate the average effectiveness and time to effective application for each device. RESULTS Eight studies reported the effectiveness of junctional tourniquets in healthy volunteers. The average effectiveness was 52% (95% CI: 15-87%) for the abdominal application of the Abdominal Aortic and Junctional Tourniquet (AAJT), 83% (95% CI: 73 to 89%, I: 26%) for the Junctional Emergency Treatment Tool (JETT), 87% (95% CI: 79 to 92%, I: 15%) for the SAM Junctional Tourniquet (SJT), and 95% (95% CI: 90-98%) for the Combat Ready Clamp (CRoC). The groin application of the AAJT was studied in two papers with 100% in both studies. The average time to application was 101 seconds for the SJT (95% CI: 50-152 seconds) and the CRoC (95% CI: 63-139 seconds), while it was 130 seconds (95% CI: 85 to 176 seconds) for the JETT. The abdominal application of AAJT had a time to application of 92 and 171 seconds in two studies. LIMITATIONS All studies were conducted in healthy volunteers. CONCLUSIONS AND IMPLICATIONS Junctional tourniquets may meet a medical need in combat, and in the civilian environment, to control hemorrhage from these difficult injuries. All four FDA-approved devices demonstrate the ability to achieve vascular occlusion in healthy volunteers; however, effectiveness in patient transport has not been evaluated, and outcomes of their use in the field needs to be captured and reported. LEVEL OF EVIDENCE Systematic review, level III.
2.
Fibrinogen in the initial resuscitation of severe trauma (FiiRST): a randomized feasibility trial
Nascimento B, Callum J, Tien H, Peng H, Rizoli S, Karanicolas P, Alam A, Xiong W, Selby R, Garzon AM, et al
British Journal of Anaesthesia. 2016;117((6)):775-782.
Abstract
BACKGROUND Decreased plasma fibrinogen concentration shortly after injury is associated with higher blood transfusion needs and mortality. In North America and the UK, cryoprecipitate transfusion is the standard-of-care for fibrinogen supplementation during acute haemorrhage, which often occurs late during trauma resuscitation. Alternatively, fibrinogen concentrate (FC) can be beneficial in trauma resuscitation. However, the feasibility of its early infusion, efficacy and safety remain undetermined. The objective of this trial was to evaluate the feasibility, effect on clinical and laboratory outcomes and complications of early infusion of FC in trauma. METHODS Fifty hypotensive (systolic arterial pressure ≤100 mm Hg) adult patients requiring blood transfusion were randomly assigned to either 6 g of FC or placebo, between Oct 2014 and Nov 2015 at a tertiary trauma centre. The primary outcome, feasibility, was assessed by the proportion of patients receiving the intervention (FC or placebo) within one h of hospital arrival. Plasma fibrinogen concentration was measured, and 28-day mortality and incidence of thromboembolic events were assessed. RESULTS Overall, 96% (43/45) [95% CI 86-99%] of patients received the intervention within one h; 95% and 96% in the FC and placebo groups, respectively (P=1.00). Plasma fibrinogen concentrations remained higher in the FC group up to 12 h after admission with the largest difference at three h (2.9 mg dL - 1 vs. 1.8 mg dL - 1; P<0.01). The 28-day mortality and thromboembolic complications were similar between groups. CONCLUSIONS Early infusion of FC is feasible and increases plasma fibrinogen concentration during trauma resuscitation. Larger trials are justified.