A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion

Khan, Shahab; Allard, Shubha; Weaver, Anne; Barber, Colin; Davenport, Ross; Brohi, Karim

doi:10.1016/j.injury.2012.09.029

Cited by 76 publications

(62 citation statements)

References 18 publications

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“…Theusinger et al [25] have demonstrated that blood management concepts to trauma patients are feasible and efficacious and Khan et al [26] have demonstrated that the implementation of haemorrhage protocols may be associated with improved blood product use and patient outcomes in trauma-haemorrhage. The survey by Hoyt et al [16] has similarly reported the frequent use of massive transfusion protocols though a huge heterogeneity was revealed by this survey with respect to the rationale of the treatment algorithm in use.…”

Section: Discussionmentioning

confidence: 99%

Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy

Driessen

Schäfer²,

Albrecht

et al. 2014

Eur J Trauma Emerg Surg

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Section: Discussionmentioning

confidence: 99%

Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy

Driessen

Schäfer²,

Albrecht

et al. 2014

Eur J Trauma Emerg Surg

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“…As the study progressed we also retrospectively reviewed the effect of changes made to practice on outcomes and blood product usage to track the THE PROGRAMME OF WORK NIHR Journals Library www.journalslibrary.nihr.ac.uk performance of our work against our stated overall objective. 12 From 2008 to 2014, 800 trauma patients activating the major haemorrhage protocol were treated at the Royal London Hospital major trauma centre and we tracked the progress and outcomes of these patients.…”

Section: Aim 3: Identification and Aim 4: Treatmentmentioning

confidence: 99%

“…The mortality rate in patients who activated the protocol was 57%. 12 Activation was tightly controlled so that wastage would be reduced. We reviewed the performance of massive transfusion prediction tools and used data from nearly 5700 trauma patients to develop our own prediction algorithm.…”

Section: Key Findings and Outputsmentioning

confidence: 99%

“…12 We progressed, limiting crystalloids, improving the delivery of products and introducing new therapeutics and evidence-based point-of-care coagulation assessments, and we saw a stepwise reduction in mortality. By the end of the programme grant mortality had reduced to 26%, with an associated reduction in all blood product administration and waste, as well as reductions in critical care and hospital stays.…”

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confidence: 99%

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Traumatic coagulopathy and massive transfusion: improving outcomes and saving blood

Brohi

Eaglestone

2017

Programme Grants Appl Res

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Introduction Dysfunction of the coagulation system, termed trauma-induced coagulopathy (TIC), is a major problem in patients who bleed after injury. Trauma haemorrhage is considered one of the leading preventable causes of death worldwide. Deaths occur early and, despite the presence of trauma teams and large transfusions of blood products, outcomes remain poor. Methods We conducted a multimodal programme of work to develop our understanding of coagulopathy and its optimal management. We studied the epidemiology, management and health economics of trauma haemorrhage, including the provision of care during mass casualty events. We combined systematic reviews of the literature with a national study of trauma haemorrhage, its transfusion management and associated health-care costs. We further examined several point-of-care coagulation tools for their ability to diagnose coagulopathy and assess the response to blood component therapy. We progressively implemented our findings into practice and assessed the outcomes of trauma patients presenting to our major trauma centre. To examine different approaches to the provision of blood to casualties in a mass casualty event, we constructed a discrete event model based on data from the 2005 London bombings. Key results Our systematic reviews found little strong evidence for the existing diagnostic tools or the practice of delivery of blood components in trauma haemorrhage. Our national study recruited 442 patients in 22 hospitals and found that the 1-year mortality rate for massive haemorrhage approached 50%. Half of these deaths occurred in the first 24 hours after injury and half of these occurred in the first 4 hours. We identified this early time window as a period when the provision of blood component therapy was often below the recommended thresholds and blood component therapy was delivered inconsistently. Studying early TIC we determined that loss of fibrinogen and excessive fibrinolysis were key derangements. We were able to determine that rotational thromboelastometry could identify early coagulopathy within 5 minutes, a large improvement on laboratory tests. We were further able to show how existing damage control resuscitation regimens with high-dose plasma do not maintain haemostatic competency during haemorrhage. In total, the estimated cost of treating a major haemorrhage patient was £20,600 and the estimated cost of treating a massive haemorrhage patient was £24,000. Nationally, the estimated cost of trauma haemorrhage is £85M annually. In mass casualty situations, early results show that the only mutable factor that affects the provision of care to a large degree, in the initial phase of the response, is the level of blood stocks held in the receiving hospital. Conclusions This multimodal programme of work has led to new understandings of the epidemiology of trauma haemorrhage and its underlying mechanisms and clinical course. We have defined diagnostic tools and trigger thresholds for identification and management and increased our understanding of how blood component and other therapeutics affect coagulopathy and when they are likely to be most effective. This diagnostic work has been taken forward at an international level to produce new personalised guidelines for the management of trauma haemorrhage. The findings have had important therapeutic implications, which have led to important changes in practice that have been incorporated into new national and international guidelines. Funding The National Institute for Health Research Programme Grants for Applied Research programme.

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“…Due to the immediacy of the situation, type specific blood is not practical; thus, O Rh(D) negative packed red blood cells and AB FFP should be ready for immediate transfusion. [8,9] However, given the limited availability of this …”

Section: Discussionmentioning

confidence: 99%

Successful emergency department thoracotomy for traumatic cardiac rupture: effective utilization of a fret sternum saw

Nakamura¹,

Masuda²,

Hitomi³

et al. 2014

Ulus Travma Acil Cerrahi Derg

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Mortality following blunt chest injury and cardiac rupture remains high despite advances in the care of traumatic injuries. Indeed, most patients succumb to these injuries even prior to reaching a hospital. However, timely recognition and surgical intervention can save lives. We present the case of a 40-year-old woman who presented to our emergency department in cardiac arrest due to rupture of her left atrium following a major motor vehicle collision. The patient underwent emergency department thoracotomy with successful repair of the cardiac rupture. Emergency department thoracotomy, when indicated and performed by trained surgeons, can be the only lifesaving procedure available. Rapid median sternotomy using a cost-effective fret sternum saw does not require significantly more time than a left lateral thoracotomy or clamshell incision in an emergency situation. It can be an effective and alternative method of thoracic entry in the emergency department. Prognosis of cardiac rupture depends largely on the mechanism of injury, location of injury, signs of life: vital signs, and availability of timely intervention. When indicated, hesitation should be avoided. Expedient cardiac exposure is essential and leads to better results with improved survival rates in patients with blunt cardiac rupture.

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A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion

Cited by 76 publications

References 18 publications

Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy

Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy

Traumatic coagulopathy and massive transfusion: improving outcomes and saving blood

Successful emergency department thoracotomy for traumatic cardiac rupture: effective utilization of a fret sternum saw

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