Abstract:Early management of critical bleeding and coagulopathy can improve patient survival. The aim of our study was to identify independent predictors of critical bleeding and to build a clinical score for early risk stratification. A prospective analysis was performed on a cohort of trauma patients with at least one hypotensive episode during pre-hospital (PH) care or in the Emergency Department (ED). Patients who received massive transfusion (MT+) (≥4 blood units during the first hour) were compared to those who d… Show more
“…Figure 1 , 2 , shows a decreasing in mortality over the time with a clear decrease of trauma mortality in late deaths. Decrease in late deaths could be ascribed to two main reasons: (a) the efficacy of damage control surgery and resuscitation in the acute phase [ 14 ], with early use of blood products, application of massive transfusion protocols [ 5 ] and on the minimization of crystalloid resuscitation [ 15 ]; (b) improvement in intensive care treatment and artificial support which allowed for an increased survival of sick patients. Late deaths, occurring days to weeks after trauma, were mainly related to hypovolemic shock and massive crystalloid resuscitation, resulting in ischemia–reperfusion mechanism with cellular damage and multiple organ disfunction (such as cardiac failure, acute renal failure, acute respiratory distress syndrome, infection and sepsis) [ 16 , 17 ] Fig.…”
Section: Discussionmentioning
confidence: 99%
“…The concept of a trimodal distribution of death in trauma played an important role in the development of trauma systems. The development of damage control techniques, specific guidelines in massive transfusion protocols, and the implementation of modern technologies in intensive care has decreased the mortality of trauma patients [ 5 , 6 ], leading to a bimodal distribution of trauma mortality [ 7 , 8 ]. The increase in the age of the trauma population, as well as the presence of comorbidities and the predominance of some mechanisms of injury (MOIs), contributed to the change in the epidemiology of trauma related deaths over the past decade [ 9 – 11 ].…”
Trauma is the leading cause of death in young people with a considerable socio-economic impact worldwide. A trimodal distribution of trauma mortality was described in the past, but recently different studies underlined a progressive change in trauma mortality distribution linked to improvement in trauma care. This study aimed to analyze the mortality trends in a Level-One Trauma Center in Italy. Data on 6065 patients consecutively admitted to the Trauma Center between 2011 and 2020 were selected and retrospectively analyzed. Causes of Death (CODs) and time of death were stratified in four main groups and the patient sample was further divided into five age groups. Multivariate regression models were then performed to identify independent predictors of mortality. The most common COD in all age groups was Central Nervous System injuries. Immediate deaths (in ED) affected mostly patients over 75 years of age (34.3%). Deaths caused by massive hemorrhage occurred soon upon arrival in the ED, whereas deaths due to other causes (e.g. sepsis, MOF) after the first week. Patients’ characteristics, the need for emergency procedures and high trauma severity scores were independent predictors of deaths. This study represented the first analysis on trauma mortality distribution in Italy over a nine-year period. The trimodal distribution described in the past seems to be no longer present in Italy, due to improvements in trauma systems and critical care. However, the high number of immediate and acute deaths underlies a persisting need for efforts in injury prevention and control .
“…Figure 1 , 2 , shows a decreasing in mortality over the time with a clear decrease of trauma mortality in late deaths. Decrease in late deaths could be ascribed to two main reasons: (a) the efficacy of damage control surgery and resuscitation in the acute phase [ 14 ], with early use of blood products, application of massive transfusion protocols [ 5 ] and on the minimization of crystalloid resuscitation [ 15 ]; (b) improvement in intensive care treatment and artificial support which allowed for an increased survival of sick patients. Late deaths, occurring days to weeks after trauma, were mainly related to hypovolemic shock and massive crystalloid resuscitation, resulting in ischemia–reperfusion mechanism with cellular damage and multiple organ disfunction (such as cardiac failure, acute renal failure, acute respiratory distress syndrome, infection and sepsis) [ 16 , 17 ] Fig.…”
Section: Discussionmentioning
confidence: 99%
“…The concept of a trimodal distribution of death in trauma played an important role in the development of trauma systems. The development of damage control techniques, specific guidelines in massive transfusion protocols, and the implementation of modern technologies in intensive care has decreased the mortality of trauma patients [ 5 , 6 ], leading to a bimodal distribution of trauma mortality [ 7 , 8 ]. The increase in the age of the trauma population, as well as the presence of comorbidities and the predominance of some mechanisms of injury (MOIs), contributed to the change in the epidemiology of trauma related deaths over the past decade [ 9 – 11 ].…”
Trauma is the leading cause of death in young people with a considerable socio-economic impact worldwide. A trimodal distribution of trauma mortality was described in the past, but recently different studies underlined a progressive change in trauma mortality distribution linked to improvement in trauma care. This study aimed to analyze the mortality trends in a Level-One Trauma Center in Italy. Data on 6065 patients consecutively admitted to the Trauma Center between 2011 and 2020 were selected and retrospectively analyzed. Causes of Death (CODs) and time of death were stratified in four main groups and the patient sample was further divided into five age groups. Multivariate regression models were then performed to identify independent predictors of mortality. The most common COD in all age groups was Central Nervous System injuries. Immediate deaths (in ED) affected mostly patients over 75 years of age (34.3%). Deaths caused by massive hemorrhage occurred soon upon arrival in the ED, whereas deaths due to other causes (e.g. sepsis, MOF) after the first week. Patients’ characteristics, the need for emergency procedures and high trauma severity scores were independent predictors of deaths. This study represented the first analysis on trauma mortality distribution in Italy over a nine-year period. The trimodal distribution described in the past seems to be no longer present in Italy, due to improvements in trauma systems and critical care. However, the high number of immediate and acute deaths underlies a persisting need for efforts in injury prevention and control .
“…William H. Rationale: Bleeding is a significant source of morbidity and mortality in trauma patients 87,88 . Adequate resuscitation is an important aspect of management of trauma patients [89][90][91] . In patients requiring surgery, under-resuscitation may delay operative treatment, and is associated with increased risk of complications.…”
mentioning
confidence: 99%
“…Prehospital care may also have an effect. A variety of scoring systems have been developed to guide clinicians in evaluating this risk 90,[92][93][94][95][96][97][98][99] .…”
The ICM-VTE Trauma Delegates* 1 -What is the most optimal VTE prophylaxis in patients with multiple orthopaedic injuries?Response/Recommendation: Although multiple forms of prophylaxis against venous thromboembolism (VTE) with variable effectiveness are available for patients with multiple orthopedic injuries, low-molecular-weight heparin (LMWH) is considered the most optimal choice based on available literature.Strength of Recommendation: Acceptable.Delegates vote: Agree 86.36% Disagree 9.09% Abstain 4.55% (Strong Consensus).Rationale: VTE events following multiple orthopaedic injuries are associated with significant morbidity and mortality 1,2 . The prevalence of deep venous thrombosis (DVT) in trauma patients without prophylactic treatment can reach up to 60%. Pulmonary embolism (PE) can be a fatal form of VTE with prevalence ranging between 2 -16% 3,4 . VTE can be prevented using different mechanical and chemical prophylaxis agents, therefore, significantly lower the burden on healthcare systems worldwide 1 . The aim of this review is to find the most optimal VTE prophylaxis in patients with multiple orthopaedic injuries.Multiple orthopaedic injuries rarely happen without extraskeletal injuries, therefore, no studies in the current literature addressed VTE prophylaxis in patients with multiple orthopaedic injuries but without extra-skeletal injuries. Most of the available literature is addressing this patient population under different groups including, patients with trauma, poly-trauma, high energy fractures and lower extremity injuries [1][2][3][5][6][7] . The level of evidence varies among the reviewed literature, however, randomized controlled clinical trials in this subject are limited 3,4 .Based on our review, LMWH is considered the most optimal VTE prophylaxis in patients with multiple orthopaedic injuries 1,3,5,6,[8][9][10][11][12][13][14] . Ley et al., recommends using LMWH due to its increased bioavailability, acceptably low bleeding complications and longer plasma half-life 1 . Rogers et al., published in their guidelines for prevention of VTE in trauma patients that LMWH has superior bioavailability when compared to lowdose heparin (LDH) 5 . Knudson et al., concluded in a prospective, randomized trial that LMWH is an extremely effective *A list of the ICM-VTE Trauma Delegates is included in a note at the end of the article. Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G855).
“…Damage-control resuscitation helps to ensure a rapid delivery of blood products in an organized fashion, allowing a reduction in trauma-induced coagulopathy (TIC) and mortality in major trauma patients 6–8 . Other relatively simple interventions like the “Stop the Bleed” program, which focuses on prehospital hemorrhage control, may help yield rapid improvements 4 . Patients with persistent hemodynamic instability due to active bleeding need surgical or radiologic intervention and immediate blood transfusion.…”
BACKGROUNDEarly detection of critical bleeding by accurate tools can help ensure rapid delivery of blood products to improve outcomes in major trauma patients. We conducted a systematic review to evaluate the accuracy of risk tools to predict critical bleeding in patients with major trauma.METHODSPubMed, Embase, and CENTRAL were searched up to February 2021 for studies investigating risk tools to predict critical bleeding for major trauma people in prehospital and emergency department. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis of Diagnostic Test Accuracy study guidelines. Two independent authors included studies, extracted data, appraised the quality using the Quality Assessment of Diagnostic Accuracy Studies 2 and assessed the certainty of evidence (CoE) using the Grading of Recommendations Assessment, Development and Evaluation methodology. Sensitivity, specificity, and the receiver operating characteristics curve for all selected triage tools.RESULTSEighty-nine observational studies for adults and 12 observational studies for children met our inclusion criteria. In adults, we found 23 externally validated and 28 unvalidated tools; in children, 3 externally validated tools and 5 unvalidated. In the externally validated tools, we identified those including clinical, laboratory, and ultrasound assessments. Among tools including only a clinical assessment, the Shock Index showed high sensitivity and specificity with the CoE ranging from very low to moderate in adults, as well as Shock Index Pediatric Age adjusted with a moderate CoE. We found that tools using clinical, laboratory, and ultrasound assessments were overall more accurate than those tools without all three components.CONCLUSIONClinicians should consider risk tools to predict critical bleeding in a time-sensitive setting like major life-threatening trauma. The Shock Index and Shock Index Pediatric Age adjusted are easy and handy tools to predict critical bleeding in the prehospital setting. In the emergency department, however, many other tools can be used, which include laboratory and ultrasound assessments, depending on staff experience and resources.LEVEL OF EVIDENCESystematic Review and Meta-Analysis; Level III.
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