Development of Novel Criteria of the “Lethal Triad” as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan

Endo, Akira; Shiraishi, Atsushi; Otomo, Yasuhiro; Kushimoto, Shigeki; Saitoh, Daizoh; Hayakawa, Mineji; Ogura, Hiroshi; Murata, Kiyoshi; Hagiwara, Akiyoshi; Sasaki, Junichi; Matsuoka, Tetsuya; Uejima, Tokuhisa; Morimura, Naoto; Ishikura, Hiroyasu; Takeda, Munekazu; Kaneko, Naoyuki; Katô, Hiroshi; Kudo, Daisuke; Kanemura, Takashi; Shibusawa, Takayuki; Hagiwara, Y.; Furugori, Shintaro; Nakamura, Yoshihiko; Maekawa, Kunihiko; Mayama, Gou; Yaguchi, Arino; Kim, Shiei; Takasu, Osamu; Nishiyama, Kazutaka

doi:10.1097/ccm.0000000000001731

Cited by 20 publications

(17 citation statements)

References 34 publications

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“…Among those who reach the hospital, early mortality has been associated with continued haemorrhage, coagulopathy and incomplete resuscitation [2]. Once the injured patient develops the ‘triad of death’, outcomes are significantly worse and reversal of coagulopathy and control of haemorrhage becomes exceedingly difficult and, in some cases, efforts may be futile [3, 4].…”

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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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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“…Endo et al . in their report stated that the classical criteria for the deadly triad were insufficient, as they showed high specificity but inadequate sensitivity, and redefined a revised criteria of the deadly triad with fibrinolytic disorder [fibrin degradation products (FDP) > 90 μg/mL], acidosis (base deficit < −3 mmol/L), and hypothermia (BT < 36 °C) 13 .…”

Section: Discussionmentioning

confidence: 99%

Decision-making criteria for damage control surgery in Japan

Urushibata

Murata

Otomo

2019

Sci Rep

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Controversy still remains regarding the optimal criteria for selecting damage control surgery (DCS). Our objective was to propose an indication for implementing DCS for abdominal trauma requiring emergency laparotomy. This was a multicenter, retrospective, observational study that used data from the Japan Trauma Data Bank. Patients who underwent emergency laparotomy were included. We compared the patients regarding the performance of DCS. Of the 4447 patients included in the study, 532 patients were in the DCS group and 3915 patients were in the non-DCS group. Logistic regression analysis revealed that body temperature, level of consciousness (Glasgow Coma Scale), and type of injury (blunt or penetrating) were independent predictors of DCS. Using these predictors, we created the Damage Control Indication Detecting score. The score showed a positive correlation with mortality. The score was obtained as 5 of 9 points in total, revealing mortality of 30.8%, sensitivity of 64.8%, and specificity of 70.0%. The area under the curve for the receiver operating characteristic curve was 0.715. This score can help surgeons determine when to perform DCS. However, more than 95% of trauma cases in Japan involve blunt injuries, suggesting that the results of our study may not be applicable internationally.

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“…TRALI is defined according to the Toronto definition, 17 and sepsis is defined according to sepsis-3. 18 Sample size In our previous retrospective multicentre observational study, wherein data were collected from 796 patients with severe trauma from 15 hospitals during a 1-year period, [19][20][21][22][23][24][25][26] 241 patients received RBC concentrates during the first 24 hours after arrival at the ED and 25% of the patients transfused with RBC concentrates died within 28 days after arrival at the ED. Based on these results, we assumed a mortality rate of 25% at 28 days after arrival in the ED among patients receiving a liberal RBC transfusion strategy.…”

Section: Secondary Outcomesmentioning

confidence: 99%

“…According to previous studies, this number of patients will allow us to study the outcomes for 2 years. [19][20][21][22][23][24][25][26] Statistical plan All analyses of the primary outcome will be adjusted for clustering within sites. The analysis will use a mixed model with adjustment for intervention, the period as a fixed effect and the sites and the interaction of site with period as a random effect.…”

Section: Secondary Outcomesmentioning

confidence: 99%

Restrictive transfusion strategy for critically injured patients (RESTRIC) trial: a study protocol for a cluster-randomised, crossover non-inferiority trial

Hayakawa

Tagami

Iijima³

et al. 2020

BMJ Open

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IntroductionResuscitation using blood products is critical during the acute postinjury period. However, the optimal target haemoglobin (Hb) levels have not been adequately investigated. With the restrictive transfusion strategy for critically injured patients (RESTRIC) trial, we aim to compare the restrictive and liberal red blood cell (RBC) transfusion strategies.Methods and analysisThis is a cluster-randomised, crossover, non-inferiority trial of patients with severe trauma at 22 hospitals that have been randomised in a 1:1 ratio based on the use of a restrictive or liberal transfusion strategy with target Hb levels of 70–90 or 100–120 g/L, respectively, during the first year. Subsequently, after 1-month washout period, another transfusion strategy will be applied for an additional year. RBC transfusion requirements are usually unclear on arrival at the emergency department. Therefore, patients with severe bleeding, which could lead to haemorrhagic shock, will be included in the trial based on the attending physician’s judgement. Each RBC transfusion strategy will be applied until 7 days postadmission to the hospital or discharge from the intensive care unit. The outcomes measured will include the 28-day survival rate after arrival at the emergency department (primary), the cumulative amount of blood transfused, event-free days and frequency of transfusion-associated lung injury and organ failure (secondary). Demonstration of the non-inferiority of restrictive transfusion will emphasise its clinical advantages.Ethics and disseminationThe trial will be performed according to the Japanese and International Ethical guidelines. It has been approved by the Ethics Committee of each participating hospital and The Japanese Association for the Surgery of Trauma (JAST). Written informed consent will be obtained from all patients or their representatives. The results of the trial will be disseminated to the participating hospitals and board-certified educational institutions of JAST, submitted to peer-reviewed journals for publication, and presented at congresses.Trial registration numberUMIN Clinical Trials Registry; UMIN000034405. Registered 8 October 2018.

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Development of Novel Criteria of the “Lethal Triad” as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan

Cited by 20 publications

References 34 publications

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

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

Decision-making criteria for damage control surgery in Japan

Restrictive transfusion strategy for critically injured patients (RESTRIC) trial: a study protocol for a cluster-randomised, crossover non-inferiority trial

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