Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients—Translating knowledge into practice

Shafi, Shahid; Collinsworth, Ashley; Richter, Kathleen; Alam, Hasan B.; Becker, Lance B.; Bullock, M. Ross; Ecklund, James M.; Gallagher, John J.; Gandhi, Raj K.; Haut, Elliott R.; Hickman, Zachary L.; Hotz, Heidi; McCarthy, James J.; Valadka, Alex B.; Weigelt, John A.; Holcomb, John B.

doi:10.1097/ta.0000000000001161

Cited by 29 publications

(17 citation statements)

References 241 publications

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“…(31) These studies suggest that implementation of a multi-modal bleeding control bundle encompassing accurate identification of the bleeding patient, transfusion, hemorrhage control techniques, devices, coagulation monitoring and process improvement in civilian trauma patients may decrease death from hemorrhage (Table 6). (32) Our data, although retrospective seem to support this concept.…”

Section: Discussionsupporting

confidence: 57%

Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care

Oyeniyi

Fox

Scerbo

et al. 2017

Injury

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219

141

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Background Over the last decade the age of trauma patients and injury mortality has increased. At the same time, many centers have implemented multiple interventions focused on improved hemorrhage control, effectively resulting in a bleeding control bundle of care. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our urban level 1 trauma center. Methods Records at a urban Level 1 trauma center were reviewed. Two time periods (2005–2006 and 2012–2013) were included in the analysis. Mortality rates were directly adjusted for age, gender and mechanism of injury. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at 0.05. Results 7080 patients (498 deaths) were examined in 2005–2006, while 8767 patients (531 deaths) were reviewed in 2012–2013. The median age increased 6 years, with a similar increase in those who died. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths are now the leading cause of death. Traumatic brain injury (TBI) and hemorrhage accounted for > 91% of all deaths. TBI (61%) and multiple organ failure or sepsis (6.2%) deaths were unchanged, while deaths associated with hemorrhage decreased from 36% to 25% (p<0.01). Across time periods, 26% of all deaths occurred within one hour of hospital arrival, while 59% occurred within 24 hours. Unadjusted mortality dropped from 7.0% to 6.1% (p=0.01) and in-hospital mortality dropped from 6.0% to 5.0% (p<0.01). Adjusted mortality dropped 24% from 7.6% (95% CI: 6.9–8.2) to 5.8% (95% CI: 5.3–6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0–7.2) to 4.7 (95% CI: 4.2–5.1). Conclusions Over the same time frame of this study, increases in trauma death across the globe have been reported. This single-site study demonstrated a significant reduction in mortality, likely attributable to decreased hemorrhagic death. It is possible that efforts focused on hemorrhage control interventions (a bleeding control bundle) resulted in this reduction. These changing factors provide guidance on future prevention and intervention efforts.

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Section: Discussionsupporting

confidence: 57%

Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care

Oyeniyi

Fox

Scerbo

et al. 2017

Injury

Self Cite

219

141

View full text Add to dashboard Cite

show abstract

“…As a result, hospital-based transfusion practice for injured patients has changed, with decreased use of crystalloid and increased use of blood products as a primary resuscitation modality, resulting in decreased complications and improved survival. 37–43 …”

Section: Discussionmentioning

confidence: 99%

Multicenter observational prehospital resuscitation on helicopter study

Holcomb

Swartz

et al. 2017

Journal of Trauma and Acute Care Surgery

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BACKGROUND Earlier use of in-hospital plasma, platelets and red blood cells (RBCs) has improved survival in trauma patients with severe hemorrhage. Retrospective studies have associated improved early survival with prehospital blood product transfusion (PHT). We hypothesized that PHT of plasma and/or RBCs would result in improved survival after injury in patients transported by helicopter. METHODS Adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers were prospectively observed from Jan–Nov 2015. Five helicopter systems had plasma and/or RBCs while the other four helicopter systems used only crystalloid resuscitation. All patients meeting predetermined high risk criteria were analyzed. Patients receiving PHT were compared to patients not receiving PHT. Our primary analysis compared mortality at 3 hours, 24 hours, and 30 days, using logistic regression to adjust for confounders and site heterogeneity to model patients who were matched on propensity scores. RESULTS 25,118 trauma patients were admitted, 2341 (9%) were transported by helicopter, of which 1058 (45%) met the highest risk criteria. 585/1058 patients were flown on helicopters carrying blood products. In the systems with blood available, prehospital median systolic blood pressure (125 vs 128) and GCS (7 vs 14) was significantly lower, while median ISS was significantly higher (21 vs 14). Unadjusted mortality was significantly higher in the systems with blood products available, at 3 (8.4% vs 3.6%), 24 (12.6% vs 8.9%) hours and 30 days (19.3% vs 13.3%). 24% of eligible patients received a prehospital transfusion. A median of 1 unit of RBCs and plasma were transfused prehospital. Of patients receiving PHT, 24% received only plasma, 7% received only RBCs and 69% received both. In the propensity score matching analysis (n=109), PHT was not significantly associated with mortality at any time point, although only 10% of the high risk sample were able to be matched. CONCLUSIONS Because of the unexpected imbalance in systolic blood pressure, GCS and ISS between systems with and without blood products on helicopters, matching was limited and the results of this study are inconclusive. With few units transfused to each patient and small outcome differences between groups, it is likely large, multicenter, randomized studies will be required to detect survival differences in this important population.

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“…In contrast to single interventions, bundles of care for resuscitation after haemorrhagic shock and severe brain injury have been previously proposed [7]. Such bundles outline treatment recommendations when a single pathological process such as haemorrhagic shock or traumatic brain injury has been identified.…”

Section: Introductionmentioning

confidence: 99%

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

et al. 2019

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Background Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients. Methods A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed. Results Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17; 95% confidence interval (CI) 0.03–0.83; p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3; 95% CI 1.4–13.0). Conclusions Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.

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Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients—Translating knowledge into practice

Cited by 29 publications

References 241 publications

Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care

Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care

Multicenter observational prehospital resuscitation on helicopter study

Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

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