PerspectivesBull World Health Organ 2013;91:386-388 | doi: http://dx

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Uncontrolled exsanguination remains the leading cause of death for trauma patients, many of whom die in the pre-hospital setting. Without expedient intervention, trauma-associated hemorrhage induces a host of systemic responses and acute coagulopathy of trauma. For this reason, health care providers and prehospital personal face the challenge of swift and effective hemorrhage control. The utilization of adjuncts to facilitate hemostasis was first recorded in 1886. Commercially available products haves since expanded to include topical hemostats, surgical sealants, and adhesives. The ideal product balances efficacy, with safety practicality and cost-effectiveness. This review of hemostasis provides a guide for successful implementation and simultaneously highlights future opportunities.

Therapeutic study, level V.

Background Lactate clearance is a standard resuscitation goal in patients in non-traumatic shock but has not been investigated adequately as a tool to identify trauma patients at risk of dying. Our objective was to determine if trauma patients with impaired lactate clearance have a higher 24-hour mortality rate than patients whose lactate concentration normalizes. Methods A retrospective chart review identified patients who were admitted directly from the scene of injury to an urban trauma center between 2010 and 2013 and who had at least one lactate concentration measurement within 24 hours. Transfers, patients without lactate measurement, and those who were dead on arrival were excluded. Of the 26,545 screened patients, 18,304 constituted the initial lactate measurement population and 3,887 were the lactate clearance cohorts. Results Initial lactate had an area-under-the-receiver operating curve of 0.86 and 0.73 for mortality at 24 hours and in-hospital, respectively. An initial concentration ≥3 mmol/L had sensitivity of 0.86 and specificity of 0.73 for mortality at 24 hours. The mortality rate among patients with elevated lactate concentrations (n=2381, 5.6±2.8 mmol/L) that did not decline to <2.0 mmol/L in response to resuscitative efforts (mean second measurement, 3.7±1.9 mmol/L) was nearly seven times higher (4.1% vs 0.6% [p<0.001]) than among those with an elevated concentration (n=1506, 5.3±2.7 mmol/L) that normalized (1.4±0.4 mmol/L). Logistic regression analysis showed that failure to clear lactate was associated with death more than any other feature (OR=7.4; CI, 1.5–35.5), except having an Injury Severity Score >25 (OR=8.2; CI, 2.7–25.2). Conclusions Failure to clear lactate is a strong negative prognostic marker after injury. An initial lactate measurement combined with a second measurement for high-risk individuals might constitute a useful method of risk-stratifying injured patients.

Hemorrhage (severe blood loss) from traumatic injury is a leading cause of death for soldiers in combat and for young civilians. In some cases, hemorrhage can be stopped by applying compression of a tourniquet or bandage at the injury site. However, the majority of hemorrhages that prove fatal are "non-compressible", such as those due to an internal injury in the truncal region. Currently, there is no effective way to treat such injuries. In this initial study, we demonstrate that a sprayable polymer-based foam can be effective at treating bleeding from soft tissue without the need for compression. When the foam is sprayed into an open cavity created by injury, it expands and forms a self-supporting barrier that counteracts the expulsion of blood from the cavity. The active material in this foam is the amphiphilic biopolymer, hydrophobically modified chitosan (hmC), which physically connects blood cells into clusters via hydrophobic interactions (the hemostatic mechanism of hmC is thus distinct from the natural clotting cascade, and it works even with heparinized or citrated blood). The amphiphilic nature of hmC also allows it to serve as a stabilizer for the bubbles in the foam. We tested the hmC-based hemostatic foam for its ability to arrest bleeding from an injury to the liver in pigs. Hemostasis was achieved within minutes after application of the hmC foams (without the need for external compression). The total blood loss was 90% lower with the hmC foam relative to controls.

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