1.
Tourniquet use for civilian extremity hemorrhage: systematic review of the literature
BenÍtez CY, Ottolino P, Pereira BM, Lima DS, Guemes A, Khan M, Ribeiro Junior MAF
Revista do Colegio Brasileiro de Cirurgioes. 2021;48:e20202783
Abstract
INTRODUCTION extremity tourniquet (TQ) use has increased in the civilian setting; the beneficial results observed in the military has influenced acceptance by EMS and bystanders. This review aimed to analyze extremity TQ types used in the civilian setting, injury site, indications, and complications. METHODS a systematic review was conducted based on original articles published in PubMed, Embase, and Cochrane following PRISMA guidelines from 2010 to 2019. Data extraction focused on extremity TQ use for hemorrhage control in the civilian setting, demographic data, study type and duration, mechanism of injury, indications for use, injury site, TQ type, TQ time, and complications. RESULTS of the 1384 articles identified, 14 were selected for review with a total of 3912 civilian victims with extremity hemorrhage and 3522 extremity TQ placements analyzed. The majority of TQs were applied to male (79%) patients, with blunt or penetrating trauma. Among the indications for TQ use were hemorrhagic shock, suspicion of vascular injuries, continued bleeding, and partial or complete traumatic amputations. Upper extremity application was the most common TQ application site (56%), nearly all applied to a single extremity (99%), and only 0,6% required both upper and lower extremity applications. 80% of the applied TQs were commercial devices, and 20% improvised. CONCLUSIONS TQ use in the civilian setting is associated with trauma-related injuries. Most are single-site TQs applied for the most part to male adults with upper extremity injury. Commercial TQs are more commonly employed, time in an urban setting is under 1 hour, with few complications described.
2.
Severely injured trauma patients with admission hyperfibrinolysis: Is there a role of tranexamic acid? Findings from the PROPPR trial
Khan M, Jehan F, Bulger EM, O'Keeffe T, Holcomb JB, Wade CE, Schreiber MA, Joseph B, PROPPR Study Group
The Journal of Trauma and Acute Care Surgery. 2018;85((5)):851-857.
-
-
Free full text
-
Abstract
INTRODUCTION Administration of tranexamic acid (TXA) in coagulopathy of trauma gained popularity after the CRASH-2 trial. The aim of our analysis was to analyze the role of TXA in severely injured trauma patients with admission hyperfibrinolysis. METHODS We reviewed the prospectively collected Pragmatic, Randomized Optimal Platelet and Plasma Ratios database. We included patients with admission hyperfibrinolysis (Ly30 >3%) on thromboelastography. Patients were stratified into two groups (TXA and No-TXA) and were matched in 1:2 ratio using propensity score matching for demographics, admission vitals, and injury severity. Primary outcome measures were 6-, 12-, and 24-hour and 30-day mortality; 24-hour transfusion requirements; time to achieve hemostasis; and rebleeding after hemostasis requiring intervention. Secondary outcome measures were thrombotic complications. RESULTS We analyzed 680 patients. Of those, 118 had admission hyperfibrinolysis, and 93 patients (TXA: 31 patients; No-TXA: 62 patients) were matched. Matched groups were similar in age (p = 0.33), gender (p = 0.84), race (p = 0.81), emergency department (ED) Glasgow Coma Scale (p = 0.34), ED systolic blood pressure (p = 0.28), ED heart rate (p = 0.43), mechanism of injury (p = 0.45), head Abbreviated Injury Scale score (p = 0.68), injury severity score (p = 0.56), and blood products ratio (p = 0.44). Patients who received TXA had a lower 6-hour mortality rate (34% vs. 13%, p = 0.04) and higher 24-hour transfusion of plasma (15 vs. 10 units, p = 0.03) compared with the No-TXA group. However, there was no difference in 12-hour (p = 0.24), 24-hour (p = 0.25), and 30-day mortality (p = 0.82). Similarly, there was no difference in 24-hour transfusion of RBC (p = 0.11) or platelets (p = 0.13), time to achieve hemostasis (p = 0.65), rebleeding requiring intervention (p = 0.13), and thrombotic complications (p = 0.98). CONCLUSION Tranexamic acid was associated with increased 6-hour survival but does not improve long-term outcomes in severely injured trauma patients with hemorrhage who develop hyperfibrinolysis. Moreover, TXA administration was not associated with thrombotic complications. Further randomized clinical trials will identify the subset of trauma patients who may benefit from TXA. LEVEL OF EVIDENCE Therapeutic study, level III.