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Current concepts on haemorrhage control in severe trauma

2020; Wiley; Volume: 90; Issue: 4 Linguagem: Inglês

10.1111/ans.15873

1445-2197

Zsolt J. Balogh, Teagan L. Way, Cino Bendinelli, Kirrily‐Rae J. Warren,

Trauma, Hemostasis, Coagulopathy, Resuscitation

ANZ Journal of SurgeryVolume 90, Issue 4 p. 406-408 EDITORIALFree Access Current concepts on haemorrhage control in severe trauma Zsolt J. Balogh MD, PhD, FRACS, Zsolt J. Balogh MD, PhD, FRACS orcid.org/0000-0002-0277-4822 Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, New South Wales, AustraliaSearch for more papers by this authorTeagan L. Way RN, MS (Trau), Teagan L. Way RN, MS (Trau) Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, New South Wales, AustraliaSearch for more papers by this authorCino Bendinelli MD, PhD, FRACS, Cino Bendinelli MD, PhD, FRACS Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, New South Wales, AustraliaSearch for more papers by this authorKirrily-Rae J. Warren MBBS, FRACS, Kirrily-Rae J. Warren MBBS, FRACS Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, New South Wales, AustraliaSearch for more papers by this author Zsolt J. Balogh MD, PhD, FRACS, Zsolt J. Balogh MD, PhD, FRACS orcid.org/0000-0002-0277-4822 Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, New South Wales, AustraliaSearch for more papers by this authorTeagan L. Way RN, MS (Trau), Teagan L. Way RN, MS (Trau) Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, New South Wales, AustraliaSearch for more papers by this authorCino Bendinelli MD, PhD, FRACS, Cino Bendinelli MD, PhD, FRACS Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, New South Wales, AustraliaSearch for more papers by this authorKirrily-Rae J. Warren MBBS, FRACS, Kirrily-Rae J. Warren MBBS, FRACS Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, New South Wales, AustraliaSearch for more papers by this author First published: 27 April 2020 https://doi.org/10.1111/ans.15873AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Polytrauma care and mortality has improved tremendously during the last 30 years. At the time of the Major Trauma Outcome Study (1982–1987), patients with an injury severity score higher than 15 had a 24% chance of dying in the USA.1 Today, most trauma centres are managing significantly older populations with overall trauma mortality usually below 10%.2 The main causes of death remain traumatic brain injury, exsanguination or physiological exhaustion due to severe bleeding, and multiple organ failure (MOF).3 While major primary and or secondary injury to brain parenchyma is the leading cause of death, traumatic shock is the most frequent cause of potentially preventable death. Further to acute exsanguination-related mortality, impaired tissue perfusion and overzealous inflammatory response to both blood loss and resuscitation can worsen traumatic brain injury and also MOF. Beyond primary injury prevention, rapid detection of blood loss, haemorrhage control and adequate resuscitation of impaired homeostasis can have the biggest impact in reducing trauma mortality. Dying from bleeding is still prevalent even within developed trauma systems. According to the latest annual report of the New Zealand National Trauma Network, the case fatality rate was 8.4% in severe trauma with 12.6% of the mortality directly attributed to bleeding and 8.1% due to MOF.4 The overwhelming majority of major trauma-related deaths are considered not preventable even with medical care provided in the most developed trauma systems (due to catastrophic brain injury, complete high spinal cord injury and free rupture of the thoracic aorta). While it feels like avoidable trauma mortality has reached a nadir where further improvement is hard to achieve, it is important for us to thrive for excellence with careful evaluation of emerging techniques and treatment modalities which have potential to decrease the preventable mortality due to exsanguination. Finding avenues to improve haemorrhage control and traumatic shock resuscitation also contributes to improved outcomes for severe traumatic brain injury and optimizes our care to simultaneously prevent MOF. The current issue of the ANZ Journal of Surgery includes articles related to life-saving approaches to address catastrophic bleeding both from the aspect of care delivery and hands-on haemorrhage control. Tovmassian et al.5 from Westmead Hospital, NSW, Australia, reported their experience with their 'Code Crimson' protocol, which is also referred as the 'Red Blanket' protocol in other centres. The terminology is long existing6 in Australasia, but without strong published evidence of its benefit. This mode of treatment is supposed to minimize the time to definitive haemorrhage control in patients with life-threatening bleeding. Typically, it truncates the time spent during the trauma resuscitation in the emergency department (ED) by avoiding unnecessary assessment, imaging and non-critical procedures to treat the obvious bleeding. Some protocols in Australia even aimed to extend this concept to prehospital decision-making and direct transfer of the patient to the operating room from the ambulance or helicopter. The Westmead Trauma Service showed significantly shorter times to the operating room from ED with Code Crimson (23 min versus 95 min) in a much more severely injured and sicker cohort with higher mortality (26% versus 7%). Code Crimson was appropriately applied to most major haemorrhage patients and was unlikely to be utilized in patients without major haemorrhage. This resulted in an obvious difference in injury severity, physiological derangements and mortality between the Code Crimson and standard pathway patients, which makes it impossible to isolate the real effect of this approach on the outcomes for severely bleeding patients. The protocol was applied only to truncal haemorrhage while severe bleeding in blunt trauma is frequently associated with multiple musculoskeletal and head injuries. While a retrospective analysis is unlikely to provide enough evidence for the concept, the 23-min median time to the operating room is a commendable achievement in in this selected group of extremely high-risk patients. The Westmead group certainly proved that timely senior decision-making can lead to expeditious transfer of the patient to definitive care within the trauma centre. Does this lead to better outcomes? We do not have an answer to that question from this paper, but we know that time is everything in critical bleeding patients to prevent irreversible homeostatic changes. We believe the critical component in expediting definitive care is the presence of the consultant surgeon in charge of the patient's management. While it sounds absolutely obvious, unfortunately in Australasia it is often not the case. No Red Blanket would move the patient to the operating room without timely decision-making and no Code Crimson would open up the theatre door without an operating surgeon. Initiations to start the process based on prehospital information are futile unless the trauma surgeon is ready to take the handover and perform a quick assessment of the arrived patient on the helipad or in the ambulance bay without offloading from the stretcher. Prehospital care providers presenting a critically injured patient to the operating theatre front desk without a prepared surgical team will not result in shorter times to arrest of the bleeding or improved outcomes. Proper prehospital and internal notification systems to activate appropriate resources and the timely presence of the treating surgeon to decide on both the urgency of haemorrhage control and on the best method(s) to achieve this can make a difference. Even with expedited transfers, trauma patients presenting in terminal shock with non-compressible torso bleeding may not have time to make it to the operating room for life-saving surgery. For these situations, most trauma centres' management algorithm includes resuscitative thoracotomy (RT) and cross clamping of the thoracic aorta above the diaphragm. Recently, the use of inflatable balloon control of the aorta (resuscitative endovascular balloon occlusion of the aorta, REBOA) has been revisited with many cases and case series published. Gaskal et al.7 queried the registry of Israel's National Center for Trauma and Emergency Medicine Research to identify, in retrospect, the potential candidates who would have benefit from REBOA. They included all adult patients who survived more than 30 min from admission but died within 24 h without significant head, neck and chest injury between 2012 and 2017. The research identified 129 (2.19%) potentially eligible patients from 5876 subjects in the registry. This group had a mean systolic blood pressure of 87 mmHg, which by itself would not necessarily classify these patients as in extremis. There were no other physiological data reported. It is also questionable how pragmatic it is to exclude all significant injuries above the diaphragm from the analysis when this is not usually possible during the timeframe when the REBOA needs to be deployed, especially in blunt polytrauma. During the same time frame, the John Hunter Hospital (largest volume trauma centre in NSW, Australia) managed more than 3000 major trauma patients and from these seven (0.02%) met the authors' inclusion criteria. Four would have been excluded due to burn- and electrocution-related injuries. The remaining three arrived with fixed dilated pupils and were palliated in the ED either due to advanced age (82 and 99 years) or no response to RT and internal cardiac massage. During the same time period, the institutional multidisciplinary mortality review panel had not identified any potentially preventable deaths due to exsanguination. Considering the intimidating complication profile of REBOA and very limited number of appropriate cases in our civilian blunt trauma setting, the potential widespread and frequent use of REBOA in Australasia should be carefully audited. Kuang and Dawson8 have written an elegant historical perspective about REBOA applications and covered some of the recently published preclinical and human studies. Three key additions to their balanced overview should be made. First, the studies where RT is compared to REBOA are looking at two fundamentally different populations, RT is usually performed when central pulse is lost and REBOA is generally inserted while the patient still has a femoral pulse.9 It is well known that the survival difference between trauma patients with and without a pulse is substantial. Second, although a large number of patients are included in the REBOA-related publications, the level of evidence of these studies is still only at the case series level.10 Third, the largest case–control study from the American College of Surgeons Trauma Quality Improvement Program data set compared 140 REBOA cases with 280 matched patients (age, gender, injury and shock severity) and concluded that the REBOA group had a higher mortality rate and a higher frequency of renal failure and lower limb amputations.11 The authors of this study urge concentrated efforts to define the patient population who could benefit from this procedure. In pursuit of eradication of the small fraction of potentially preventable trauma deaths, we would like to urge Australasian trauma centres to carefully evaluate their bleeding-related potentially preventable mortality cases during the current era of modern trauma care with haemostatic resuscitation. The more than likely very limited number of situations when the benefits of REBOA use outweigh the associated risks could then be identified. References 1Champion HR, Copes WS, Sacco WJ et al. The Major Trauma Outcome Study: establishing national norms for trauma care. J. Trauma 1990; 30: 1356– 65. CrossrefCASPubMedWeb of Science®Google Scholar 2Wong TH, Lumsdaine W, Hardy BM, Lee K, Balogh ZJ. The impact of specialist trauma service on major trauma mortality. J. Trauma Acute Care Surg. 2013; 74: 780– 4. CrossrefPubMedWeb of Science®Google Scholar 3Evans JA, van Wessem KJ, McDougall D, Lee KA, Lyons T, Balogh ZJ. Epidemiology of traumatic deaths: comprehensive population-based assessment. World J. Surg. 2010; 34: 158– 63. CrossrefPubMedWeb of Science®Google Scholar 4 New Zealand Trauma Network. Annual report 2018-2019. 2020. Available from URL: https://www.majortrauma.nz/assets/Publication-Resources/Annual-reports/National-Trauma-Network-Annual-Report-2018-19.pdfGoogle Scholar 5Tovmassian et al. Process measure aimed at reducing time to hemorrhage control: Outcomesassociated with Code Crimson activation in exsanguinating truncal trauma. ANZ J. Surg. 2020. Wiley Online LibraryPubMedGoogle Scholar 6Grabs AJ, May AN, Fulde GW, McDonell KA. Code crimson: a life-saving measure to treat exsanguinating emergencies in trauma. ANZ J. Surg. 2008; 78: 523– 5. Wiley Online LibraryPubMedWeb of Science®Google Scholar 7Gaskal et al. Potential REBOA candidates: defining the potential need using the National Trauma Registry. ANZ J. Surg. 2020. Web of Science®Google Scholar 8Kuang et al. The resuscitation of REBOA. ANZ J. Surg. 2020. Wiley Online LibraryPubMedWeb of Science®Google Scholar 9Moore LJ, Brenner M, Kozar RA et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J. Trauma Acute Care Surg. 2015; 79: 523– 30. CrossrefPubMedWeb of Science®Google Scholar 10Petrone P, Pérez-Jiménez A, Rodríguez-Perdomo M, Brathwaite CEM, Joseph DK. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of trauma patients: a systematic literature review. Am. Surg. 2019; 85: 654– 62. CrossrefPubMedWeb of Science®Google Scholar 11Joseph B, Zeeshan M, Sakran JV et al. Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta in civilian trauma. JAMA Surg. 2019; 154: 500– 8. CrossrefPubMedWeb of Science®Google Scholar Volume90, Issue4April 2020Pages 406-408 ReferencesRelatedInformation