Transfusion management of trauma from the 2019 El Paso mass shooting incident

Abstract

Background and Objectives: Mortality rates, transfusion ratios, trauma management logistics, and assault characteristics from the El Paso mass shooting incident (MSI) are evaluated in comparison to other MSIs. In 2019, El Paso, TX experienced the eighth-deadliest MSIs in modern US history. In this 21st mass killing in the United States of 2019, 19 people died immediately, and four of 27 injured, later died from ballistic injuries. Materials and Methods: We examined the victims' injuries, pre-hospital treatments, transfusions, rotational thromboelastometry (ROTEM) interpretation, tranexamic acid (TXA) use, and compared El Paso's outcomes with other MSIs.Results: Fifteen casualties were treated for bullet injuries at University Medical Center (UMC). Three were in critical condition; one died during surgery. Of the remaining victims, two were guarded, and the remaining ten in stable condition. Anatomic trauma locations included chest, abdomen, hip, breast, thigh and arm. Haemostatic agents and TXA were administered to arriving patients. Seven casualties receiving blood products were administered 95 units at UMC (45 red blood cells [RBC], 38 fresh frozen plasma[FFP], 8 platelets and 4 cryoprecipitate). ROTEM guided mass transfusion decisions in three patients. Out of seven MSIs reviewed, El Paso had the highest mortality rate (50.0%) and lowest RBC:FFP:admission ratio (1.18 at UMC). Conclusion:We report the greatest proportion of transfusions per admission for an MSI and are first to discuss ROTEM roles to guide transfusion and manage coagulopathy during an MSI. This case highlights the severity and impact of MSIs on victims and requirements to follow established transfusion protocols with adjunct use of ROTEM, TXA and haemostatic agents.

Intramuscular administration of tranexamic acid in a large swine model of hemorrhage with hyperfibrinolysis

“…Deployment of battlefield treatments, such as TXA, to civilian medicine has been shown to reduce mortality. 13 Other studies have reported IM and IV administration of TXA is effective in treating hyperfibrinolysis in vitro. However, to the best of our knowledge, this is the first in vivo model of acute hemorrhage to show that IM TXA is equally efficacious as IV TXA in preventing pharmaceutically induced hyperfibrinolysis.…”

“…Deployment of battlefield treatments, such as TXA, to civilian medicine has been shown to reduce mortality 13 . Other studies have reported IM and IV administration of TXA is effective in treating hyperfibrinolysis in vitro.…”

“…11,12 Current Tactical Combat Casualty Care and Military Clinical Practice Guidelines, as well as civilian trauma centers, recommend intravenous (IV) TXA administration within 3 hours of severe traumatic injury. 13,14 Its use has been shown to reduce mortality when given within these first 3 hours. [15][16][17] However, obtaining IVaccess in a hemorrhaging, hypotensive patient in an austere environment can be challenging and can lead to delays in therapeutic intervention, including TXA administration.…”

“…The Food and Drug Administration–approved antifibrinolytic tranexamic acid (TXA) is a synthetic lysine analog that inhibits plasminogen activation, thereby leading to decreased clot lysis 11,12 . Current Tactical Combat Casualty Care and Military Clinical Practice Guidelines, as well as civilian trauma centers, recommend intravenous (IV) TXA administration within 3 hours of severe traumatic injury 13,14 . Its use has been shown to reduce mortality when given within these first 3 hours 15–17 .…”