Iain M. Smith

Prehospital Blood Product Resuscitation for Trauma: A Systematic Review.

Introduction: Administration of high ratios of plasma to packed red blood cells is a routine practice for in-hospital trauma resuscitation. Military and civilian emergency teams are increasingly carrying prehospital blood products (PHBP) for trauma resuscitation. This study systematically reviewed the clinical literature to determine the extent to which the available evidence supports this practice. Methods: Bibliographic databases and other sources were searched to July 2015 using keywords and index terms related to the intervention, setting, and condition. Standard systematic review methodology aimed at minimizing bias was used for study selection, data extraction, and quality assessment (protocol registration PROSPERO: CRD42014013794). Synthesis was mainly narrative with random effects model meta-analysis limited to mortality outcomes. Results: No prospective comparative or randomized studies were identified. Sixteen case series and 11 comparative studies were included in the review. Seven studies included mixed populations of trauma and non-trauma patients. Twenty-five of 27 studies provided only very low quality evidence. No association between PHBP and survival was found (OR for mortality: 1.29, 95% CI: 0.84–1.96, P = 0.24). A single study showed improved survival in the first 24 h. No consistent physiological or biochemical benefit was identified, nor was there evidence of reduced in-hospital transfusion requirements. Transfusion reactions were rare, suggesting the short-term safety of PHBP administration. Conclusions: While PHBP resuscitation appears logical, the clinical literature is limited, provides only poor quality evidence, and does not demonstrate improved outcomes. No conclusions as to efficacy can be drawn. The results of randomized controlled trials are awaited.

A Prospective Observational Study of Abdominal Injury Management in Contemporary Military Operations: Damage Control Laparotomy Is Associated With High Survivability and Low Rates of Fecal Diversion

OBJECTIVE This study describes the cause, management, and outcomes of abdominal injury in a mature deployed military trauma system, with particular focus on damage control, hollow visceral injury (HVI), and stoma utilization. BACKGROUND Damage control laparotomy (DCL) is established in military and civilian practice. However, optimal management of HVI during military DCL remains controversial. METHODS We studied abdominal trauma managed over 5 months at the Joint Force Combat Support Hospital, Camp Bastion, Afghanistan (Role 3). Data included demographics, wounding mechanism, injuries sustained, prehospital times, location of first laparotomy (Role 3 or forward), use of DCL or definitive laparotomy, subsequent surgical details, resource utilization, complications, and mortality. RESULTS Ninety-four of 636 trauma patients (15%) underwent laparotomy. Military injury mechanisms dominated [44 gunshot wounds (47%), 44 blast (47%), and 6 blunt trauma (6%)]. Seventy-two of 94 patients (77%) underwent DCL. Four patients were palliated. Seventy of 94 (74%) sustained HVI; 44 of 70 (63%) had colonic injury. Repair or resection with anastomosis was performed in 59 of 67 therapeutically managed HVI patients (88%). Six patients were managed with fecal diversion, and 6 patients were evacuated with discontinuous bowel. Anastomotic leaks occurred in 4 of 56 HVI patients (7%) with known outcomes. Median New Injury Severity Score for DCL patients was 29 (interquartile range: 18-41) versus 19.5 (interquartile range: 12-34) for patients undergoing definitive laparotomy (P = 0.016). Overall mortality was 15 of 94 (16%). CONCLUSIONS Damage control is now used routinely for battlefield abdominal trauma. In a well-practiced Combat Support Hospital, this strategy is associated with low mortality and infrequent fecal diversion.

Scanning and War: Utility of FAST and CT in the Assessment of Battlefield Abdominal Trauma.

OBJECTIVE To determine utilization and accuracy of focused assessment with sonography for trauma (FAST) and computed tomography (CT) in a mature military trauma system to inform service provision for future conflicts. BACKGROUND FAST and CT scans undertaken by attending radiologists contribute to surgical decision making for battlefield casualties at the Joint Force, Role 3 Medical Treatment Facility at Camp Bastion (R3), Afghanistan. METHODS Registry data for abdominally injured casualties treated at R3 from July to November 2012 were matched to radiological and surgical records to determine diagnostic accuracy for FAST and CT and their influence on casualty management. RESULTS A total of 468 casualties met inclusion criteria, of whom 85.0% underwent FAST and 86.1% abdominal CT; 159 (34.0%) had abdominal injuries. For detection of intra-abdominal injury, FAST sensitivity (Sn) was 0.56, specificity (Sp) 0.98, positive predictive value (PPV) 0.87, negative predictive value (NPV) 0.90, and accuracy (Acc) 0.89. For CT, Sn was 0.99, Sp 0.99, PPV 0.96, NPV 1.00, and Acc 0.99. Forty-six solid organ injuries were identified in 38 patients by CT; 17 were managed nonoperatively. A further 61 patients avoided laparotomy after CT confirmed extra-abdominal wounds only. The negative laparotomy rate was 3.9%. CONCLUSIONS FAST and CT contribute to triage, guide surgical management, and reduce nontherapeutic laparotomy. When imaging is available, these data challenge current doctrine about inadvisability of nonoperative management of abdominal injury after combat trauma.

Protocol for a systematic review of the clinical effectiveness of pre-hospital blood components compared to other resuscitative fluids in patients with major traumatic haemorrhage.

BackgroundThere is growing interest in the use of blood components for pre-hospital resuscitation of patients with major traumatic haemorrhage. It has been speculated that early resuscitation with blood components may have benefits in terms of treating trauma-induced coagulopathy, which in turn may influence survival. The proposed systematic review will evaluate the evidence on the clinical effectiveness of pre-hospital blood components (red blood cells and/or plasma or whole blood), in both civilian and military settings, compared with other resuscitation strategies in patients with major traumatic haemorrhage.Methods/designStandard systematic review methods aimed at minimising bias will be employed for study identification, selection and data extraction. General medical and specialist databases will be searched; the search strategy will combine terms for the population, intervention and setting. Studies will be selected for review if the population includes adult patients with major traumatic haemorrhage who receive blood components in a pre-hospital setting (civilian or military). Systematic reviews, randomised and non-randomised controlled trials and controlled observational studies will be included. Uncontrolled studies will be considered depending on the volume of controlled evidence. Quality assessment will be tailored to different study designs. Both patient related and surrogate outcomes will be considered. Synthesis is likely to be primarily narrative, but meta-analyses and subgroup analyses will be undertaken where clinical and methodological homogeneity exists.DiscussionGiven the increasing use by emergency services of blood components for pre-hospital resuscitation, this is a timely systematic review, which will attempt to clarify the evidence base for this practice. As far as the authors are aware, the proposed systematic review will be the first to address this topic.Systematic review registrationPROSPERO CRD42014013794

Safety and feasibility of sublingual microcirculation assessment in the emergency department for civilian and military patients with traumatic haemorrhagic shock: a prospective cohort study

Objectives Sublingual microcirculatory monitoring for traumatic haemorrhagic shock (THS) may predict clinical outcomes better than traditional blood pressure and cardiac output, but is not usually performed until the patient reaches the intensive care unit (ICU), missing earlier data of potential importance. This pilot study assessed for the first time the feasibility and safety of sublingual video-microscopy for THS in the emergency department (ED), and whether it yields useable data for analysis. Setting A safety and feasibility assessment was undertaken as part of the prospective observational MICROSHOCK study; sublingual video-microscopy was performed at the UK-led Role 3 medical facility at Camp Bastion, Afghanistan, and in the ED in 3 UK Major Trauma Centres. Participants There were 15 casualties (2 military, 13 civilian) who presented with traumatic haemorrhagic shock with a median injury severity score of 26. The median age was 41; the majority (n=12) were male. The most common injury mechanism was road traffic accident. Primary and secondary outcome measures Safety and feasibility were the primary outcomes, as measured by lack of adverse events or clinical interruptions, and successful acquisition and storage of data. The secondary outcome was the quality of acquired video clips according to validated criteria, in order to determine whether useful data could be obtained in this emergency context. Results Video-microscopy was successfully performed and stored for analysis for all patients, yielding 161 video clips. There were no adverse events or episodes where clinical management was affected or interrupted. There were 104 (64.6%) video clips from 14 patients of sufficient quality for analysis. Conclusions Early sublingual microcirculatory monitoring in the ED for patients with THS is safe and feasible, even in a deployed military setting, and yields videos of satisfactory quality in a high proportion of cases. Further investigations of early microcirculatory behaviour in this context are warranted. Trial registration number NCT02111109.

Deployed skills training for whole blood collection by a special operations expeditionary surgical team.

BACKGROUND Noncompressible hemorrhage is the leading cause of potentially preventable battlefield death. Combining casualty retrieval from the battlefield and damage control resuscitation (DCR) within the “golden hour” increases survival. However, transfusion requirements may exceed the current blood component stocks held by forward surgical teams. Warm fresh whole blood (WFWB) is an alternative. We report WFWB transfusion training developed by and delivered to a US Golden Hour Offset Surgical Treatment Team and the resulting improvement in confidence with WFWB transfusion. METHODS A bespoke instructional package was derived from existing operational clinical guidelines. All Golden Hour Offset Surgical Treatment Team personnel completed initial training, reinforced through ongoing casualty simulations. A record of blood types and donor eligibility was established to facilitate rapid identification of potential WFWB donors. Self-reported confidence in seven aspects of the WFWB transfusion process was assessed before and after training using a five-point Likert scale. Personnel were analyzed by groups consisting of those whose operational role includes WFWB transfusion (“transfusers”), clinical personnel without such responsibilities (“nontransfusers”) and nonclinical personnel (other). Comparisons within and between groups were made using appropriate nonparametric tests. RESULTS Data were collected from 39 (89%) of 44 training participants: 24 (62%) transfusers, 12 (31%) nontransfusing clinicians, and 3 (8%) other personnel. Transfusers and nontransfusers reported increased comfort with all practical elements of WFWB transfusion. The confidence of other personnel also increased, but (likely due to small numbers) was not statistically significant. CONCLUSION WFWB transfusion is an integral part of modern deployed military remote DCR. Our in-theater training program rapidly and reproducibly enhanced the comfort in WFWB transfusion in providers from a range of backgrounds and skill-mixes. This model has the potential to improve both safety and effectiveness of WFWB remote DCR in the far-forward deployed setting. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.

An adapted Clavien-Dindo scoring system in trauma as a clinically meaningful non-mortality endpoint

BACKGROUND There is no consensus on reporting nonmortality trauma complications in a graded manner. The Clavien-Dindo scale of complications was originally for elective surgery and requires adaptation to provide meaningful data for trauma patients. In particular, the original score does not account for those treated without surgery. We report an adapted Clavien-Dindo in trauma (ACDiT) scale and apply it to patients managed operatively and nonoperatively. METHODS A combined prospective and retrospective international multicenter observational study was undertaken to apply the ACDiT scale to 484 trauma patients at three university teaching hospitals (Birmingham, England (n = 303); Houston, Texas (n = 113); and Glasgow, Scotland (n = 68)). These included both intensive care unit (ICU) and non–ICU-managed patients. The Clavien-Dindo scoring system was adapted for trauma patients based on consensus amongst an international collaboration of trauma specialists at these sites. Data included whether initial patients were managed operatively or nonoperatively. Complication grades were compared with hospital-free and ICU-free days as other outcome measures of patient morbidity. RESULTS Two hundred seventeen (44.8%) of 484 patients experienced complications, of whom 61 (28.1%) of 217 died (grade V). The remainder consisted of grades I (n = 20), II (n = 60), III (n = 24), and IV (n = 52). There was a strong association between higher ACDiT grade category and lower number of hospital-free and ICU-free days (p < 0.01). Eighty-eight patients with complications did not require surgery, validating the score’s usefulness in patients managed nonoperatively. CONCLUSION The ACDiT scale can be used to grade the severity of posttrauma complications in patients managed both operatively and nonoperatively. It provides clinically meaningful data for morbidity and mortality meetings and other quality improvement exercises. LEVEL OF EVIDENCE Prognostic, level IV.

What fluids are given during air ambulance treatment of patients with trauma in the UK, and what might this mean for the future? Results from the RESCUER observational cohort study

Objectives We investigated how often intravenous fluids have been delivered during physician-led prehospital treatment of patients with hypotensive trauma in the UK and which fluids were given. These data were used to estimate the potential national requirement for prehospital blood products (PHBP) if evidence from ongoing trials were to report clinical superiority. Setting The Regional Exploration of Standard Care during Evacuation Resuscitation (RESCUER) retrospective observational study was a collaboration between 11 UK air ambulance services. Each was invited to provide up to 5 years of data and total number of taskings during the same period. Participants Patients with hypotensive trauma (systolic blood pressure <90 mm Hg or absent radial pulse) attended by a doctor. Primary and secondary outcome measures The primary outcome was the number of patients with hypotensive trauma given prehospital fluids. Secondary outcomes were types and volumes of fluids. These data were combined with published data to estimate potential national eligibility for PHBP. Results Of 29 037 taskings, 729 (2.5%) were for patients with hypotensive trauma attended by a physician. Half were aged 21–50 years; 73.4% were male. A total of 537 out of 729 (73.7%) were given fluids. Five hundred and ten patients were given a single type of fluid; 27 received >1 type. The most common fluid was 0.9% saline, given to 486/537 (90.5%) of patients who received fluids, at a median volume of 750 (IQR 300–1500) mL. Three per cent of patients received PHBP. Estimated projections for patients eligible for PHBP at these 11 services and in the whole UK were 313 and 794 patients per year, respectively. Conclusions One in 40 air ambulance taskings were manned by physicians to retrievepatients with hypotensive trauma. The most common fluid delivered was 0.9% saline. If evidence justifies universal provision of PHBP, approximately 800 patients/year would be eligible in the UK, based on our data combined with others published. Prospective investigations are required to confirm or adjust these estimations.