-
Journal of Thrombosis and Haemostasis :... Jun 2019Trauma remains a leading cause of death worldwide, and most early preventable deaths in both the civilian and military settings are due to uncontrolled hemorrhage,... (Review)
Review
Trauma remains a leading cause of death worldwide, and most early preventable deaths in both the civilian and military settings are due to uncontrolled hemorrhage, despite paradigm advances in modern trauma care. Combined tissue injury and shock result in hemostatic failure, which has been identified as a multidimensional molecular, physiologic and clinical disorder termed trauma-induced coagulopathy (TIC). Understanding the biology of TIC is of utmost importance, as it is often responsible for uncontrolled bleeding, organ failure, thromboembolic complications, and death. Investigations have shown that TIC is characterized by multiple phenotypes of impaired hemostasis due to altered biology in clot formation and breakdown. These coagulopathies are attributable to tissue injury and shock, and encompass underlying endothelial, immune and inflammatory perturbations. Despite the recognition and identification of multiple mechanisms and mediators of TIC, and the development of targeted treatments, the mortality rates and associated morbidities due to hemorrhage after injury remain high. The purpose of this review is to examine the past and present understanding of the multiple distinct but highly integrated pathways implicated in TIC, in order to highlight the current knowledge gaps and future needs in this evolving field, with the aim of reducing morbidity and mortality after injury.
Topics: Blood Coagulation Disorders; Blood Coagulation Factors; Blood Platelets; Endothelium; Exsanguination; Fibrinolysis; Hemorrhage; Hemostasis; Humans; Protein C; Shock, Hemorrhagic; Wounds and Injuries
PubMed: 30985957
DOI: 10.1111/jth.14450 -
Obstetrics and Gynecology Sep 2023Vasa previa refers to unprotected fetal vessels running through the membranes over the cervix. Until recently, this condition was associated with an exceedingly high...
Vasa previa refers to unprotected fetal vessels running through the membranes over the cervix. Until recently, this condition was associated with an exceedingly high perinatal mortality rate attributable to fetal exsanguination when the membranes ruptured. However, ultrasonography has made it possible to diagnose the condition prenatally, allowing cesarean delivery before labor or rupture of the membranes. Several recent studies have indicated excellent outcomes with prenatally diagnosed vasa previa. However, outcomes continue to be dismal when vasa previa is undiagnosed before labor. Risk factors for vasa previa include second-trimester placenta previa and low-lying placentas, velamentous cord insertion, placentas with accessory lobes, in vitro fertilization, and multifetal gestations. Recognition of individuals who are at risk and screening them will greatly decrease the mortality rate from this condition. Because of the relative rarity of vasa previa, there are no randomized controlled trials to guide management. Therefore, recommendations on the diagnosis and management of vasa previa are based largely on cohort studies and expert opinion. This Clinical Expert Series review addresses the epidemiology, pathophysiology, natural history, diagnosis and management of vasa previa, as well as innovative treatments for the condition.
Topics: Female; Pregnancy; Humans; Vasa Previa; Cesarean Section; Fertilization in Vitro; Fetus; Labor, Obstetric
PubMed: 37590981
DOI: 10.1097/AOG.0000000000005287 -
JAMA Nov 2023Bleeding is the most common cause of preventable death after trauma.
IMPORTANCE
Bleeding is the most common cause of preventable death after trauma.
OBJECTIVE
To determine the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) when used in the emergency department along with standard care vs standard care alone on mortality in trauma patients with exsanguinating hemorrhage.
DESIGN, SETTING, AND PARTICIPANTS
Pragmatic, bayesian, randomized clinical trial conducted at 16 major trauma centers in the UK. Patients aged 16 years or older with exsanguinating hemorrhage were enrolled between October 2017 and March 2022 and followed up for 90 days.
INTERVENTION
Patients were randomly assigned (1:1 allocation) to a strategy that included REBOA and standard care (n = 46) or standard care alone (n = 44).
MAIN OUTCOMES AND MEASURES
The primary outcome was all-cause mortality at 90 days. Ten secondary outcomes included mortality at 6 months, while in the hospital, and within 24 hours, 6 hours, or 3 hours; the need for definitive hemorrhage control procedures; time to commencement of definitive hemorrhage control procedures; complications; length of stay; blood product use; and cause of death.
RESULTS
Of the 90 patients (median age, 41 years [IQR, 31-59 years]; 62 [69%] were male; and the median Injury Severity Score was 41 [IQR, 29-50]) randomized, 89 were included in the primary outcome analysis because 1 patient in the standard care alone group declined to provide consent for continued participation and data collection 4 days after enrollment. At 90 days, 25 of 46 patients (54%) had experienced all-cause mortality in the REBOA and standard care group vs 18 of 43 patients (42%) in the standard care alone group (odds ratio [OR], 1.58 [95% credible interval, 0.72-3.52]; posterior probability of an OR >1 [indicating increased odds of death with REBOA], 86.9%). Among the 10 secondary outcomes, the ORs for mortality and the posterior probabilities of an OR greater than 1 for 6-month, in-hospital, and 24-, 6-, or 3-hour mortality were all increased in the REBOA and standard care group, and the ORs were increased with earlier mortality end points. There were more deaths due to bleeding in the REBOA and standard care group (8 of 25 patients [32%]) than in standard care alone group (3 of 18 patients [17%]), and most occurred within 24 hours.
CONCLUSIONS AND RELEVANCE
In trauma patients with exsanguinating hemorrhage, a strategy of REBOA and standard care in the emergency department does not reduce, and may increase, mortality compared with standard care alone.
TRIAL REGISTRATION
isrctn.org Identifier: ISRCTN16184981.
Topics: Humans; Male; Adult; Female; Exsanguination; Bayes Theorem; Retrospective Studies; Hemorrhage; Aorta; Balloon Occlusion; Resuscitation; Injury Severity Score; Emergency Service, Hospital; United Kingdom
PubMed: 37824132
DOI: 10.1001/jama.2023.20850 -
JAMA Feb 2015Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials.
OBJECTIVE
To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio.
DESIGN, SETTING, AND PARTICIPANTS
Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013.
INTERVENTIONS
Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled).
MAIN OUTCOMES AND MEASURES
Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status.
RESULTS
No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.
CONCLUSIONS AND RELEVANCE
Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups.
TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT01545232.
Topics: Blood Component Transfusion; Blood Platelets; Erythrocytes; Exsanguination; Female; Hemostasis; Humans; Male; Plasma; Shock, Hemorrhagic; Wounds and Injuries
PubMed: 25647203
DOI: 10.1001/jama.2015.12 -
Journal of Clinical Medicine Dec 2022Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from... (Review)
Review
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
PubMed: 36615060
DOI: 10.3390/jcm12010260 -
International Journal of Molecular... Apr 2023Trauma remains one of the leading causes of death in adults despite the implementation of preventive measures and innovations in trauma systems. The etiology of... (Review)
Review
Trauma remains one of the leading causes of death in adults despite the implementation of preventive measures and innovations in trauma systems. The etiology of coagulopathy in trauma patients is multifactorial and related to the kind of injury and nature of resuscitation. Trauma-induced coagulopathy (TIC) is a biochemical response involving dysregulated coagulation, altered fibrinolysis, systemic endothelial dysfunction, platelet dysfunction, and inflammatory responses due to trauma. The aim of this review is to report the pathophysiology, early diagnosis and treatment of TIC. A literature search was performed using different databases to identify relevant studies in indexed scientific journals. We reviewed the main pathophysiological mechanisms involved in the early development of TIC. Diagnostic methods have also been reported which allow early targeted therapy with pharmaceutical hemostatic agents such as TEG-based goal-directed resuscitation and fibrinolysis management. TIC is a result of a complex interaction between different pathophysiological processes. New evidence in the field of trauma immunology can, in part, help explain the intricacy of the processes that occur after trauma. However, although our knowledge of TIC has grown, improving outcomes for trauma patients, many questions still need to be answered by ongoing studies.
Topics: Adult; Humans; Critical Illness; Blood Coagulation Disorders; Blood Coagulation; Fibrinolysis; Hemostatics; Wounds and Injuries
PubMed: 37108280
DOI: 10.3390/ijms24087118 -
Gastroenterology Research Aug 2022Flood syndrome refers to the exsanguination of ascitic fluid following the spontaneous rupture of an umbilical hernia, and is a rare complication of liver cirrhosis with...
Flood syndrome refers to the exsanguination of ascitic fluid following the spontaneous rupture of an umbilical hernia, and is a rare complication of liver cirrhosis with ascites. In this case report, we describe a 67-year-old patient with Flood syndrome who was initially managed conservatively in a community hospital run by primary care physicians, prior to transfer to a tertiary hospital for specialist surgical review and management. We also performed a literature review of the current treatment modalities to manage this condition.
PubMed: 36128184
DOI: 10.14740/gr1508