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IMPORTANCE: Hemorrhage is the most common cause of preventable death after injury. Most deaths occur early, in the prehospital phase of care. OBJECTIVE: To establish whether prehospital zone 1 (supraceliac) partial resuscitative endovascular balloon occlusion of the aorta (Z1 P-REBOA) can be achieved in the resuscitation of adult trauma patients at risk of cardiac arrest and death due to exsanguination. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective observational cohort study (Idea, Development, Exploration, Assessment and Long-term follow-up [IDEAL] 2A design) with recruitment from June 2020 to March 2022 and follow-up until discharge from hospital, death, or 90 days evaluating a physician-led and physician-delivered, urban prehospital trauma service in the Greater London area. Trauma patients aged 16 years and older with suspected exsanguinating subdiaphragmatic hemorrhage, recent or imminent hypovolemic traumatic cardiac arrest (TCA) were included. Those with unsurvivable injuries or who were pregnant were excluded. Of 2960 individuals attended by the service during the study period, 16 were included in the study. EXPOSURES: ZI REBOA or P-REBOA. MAIN OUTCOMES AND MEASURES: The main outcome was the proportion of patients in whom Z1 REBOA and Z1 P-REBOA were achieved. Clinical end points included systolic blood pressure (SBP) response to Z1 REBOA, mortality rate (1 hour, 3 hours, 24 hours, or 30 days postinjury), and survival to hospital discharge. RESULTS: Femoral arterial access for Z1 REBOA was attempted in 16 patients (median [range] age, 30 [17-76] years; 14 [81%] male; median [IQR] Injury Severity Score, 50 [39-57]). In 2 patients with successful arterial access, REBOA was not attempted due to improvement in clinical condition. In the other 14 patients (8 [57%] of whom were in traumatic cardiac arrest [TCA]), 11 successfully underwent cannulation and had aortic balloons inflated in Z1. The 3 individuals in whom cannulation was unsuccessful were in TCA (failure rate = 3/14 [21%]). Median (IQR) pre-REBOA SBP in the 11 individuals for whom cannulation was successful (5 [46%] in TCA) was 47 (33-52) mm Hg. Z1 REBOA plus P-REBOA was associated with a significant improvement in BP (median [IQR] SBP at emergency department arrival, 101 [77-107] mm Hg; 0 of 10 patients were in TCA at arrival). The median group-level improvement in SBP from the pre-REBOA value was 52 (95% CI, 42-77) mm Hg (P < .004). P-REBOA was feasible in 8 individuals (8/11 [73%]) and occurred spontaneously in 4 of these. The 1- and 3-hour postinjury mortality rate was 9% (1/11), 24-hour mortality was 27% (3/11), and 30-day mortality was 82% (9/11). Survival to hospital discharge was 18% (2/11). Both survivors underwent early Z1 P-REBOA. CONCLUSIONS AND RELEVANCE: In this study, prehospital Z1 P-REBOA is feasible and may enable early survival, but with a significant incidence of late death. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04145271

Rotational thromboelastometry (ROTEM) is used to rapidly identify trauma-induced coagulopathy (TIC) and direct targeted interventions in hemorrhaging trauma patients. A novel technology, Quantra System (HemoSonics), utilizes sonic estimation of elasticity via resonance sonorheometry, avoids mechanical clot interference, and may increase diagnostic accuracy, but there are limited data on bleeding in major trauma patients.

Most studies describing traumatic coagulopathy have used data from patient cohorts with an average age of between 35 and 45 years. The last 10 years has seen a steep increase in the number of patients admitted with significant injury and bleeding who are older than the age of 65 years. Many coagulation protein levels alter significantly with normal aging, and it is possible that traumatic coagulopathy has a different signature with age.

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ObjectiveIn the era of damage control resuscitation of trauma patients with acute major haemorrhage, transfusion practice has evolved to blood component (component therapy) administered in a ratio that closely approximates whole blood (WB). However, there is a paucity of evidence supporting the optimal transfusion strategy in these patients. The primary objective was therefore to establish if there is an improvement in survival at 30 days with the use of WB transfusion compared with blood component therapy in adult trauma patients with acute major haemorrhage.MethodologyA systematic literature search was performed on 15 December 2019 to identify studies comparing WB transfusion with component therapy in adult trauma patients and mortality at 30 days. Studies which did not report mortality were excluded. Methodological quality of included studies was interpreted using the Cochrane risk of bias tool, and rated using the Grading of Recommendations Assessment, Development and Evaluation approach.ResultsSearch of the databases identified 1885 records, and six studies met the inclusion criteria involving 3255 patients. Of the three studies reporting 30-day mortality (one randomised controlled trial (moderate evidence) and two retrospective (low and very low evidence, respectively)), only one study demonstrated a statistically significant difference between WB and component therapy, and two found no statistical difference. Two retrospective studies reporting in-hospital mortality found no statistical difference in unadjusted mortality, but both reported statistically significant logistic regression analyses demonstrating that those with a WB transfusion strategy were less likely to die.ConclusionRecognising the limitations of this systematic review relating to the poor-quality evidence and limited number of included trials, it does not provide evidence to support or reject use of WB transfusion compared with component therapy for adult trauma patients with acute major haemorrhage.PROSPERO registration numberCRD42019131406.

Uncontrolled haemorrhage is the leading cause of preventable death from injury and is a major contributor to the global burden of disease. The majority of deaths resulting from bleeding occur within the first 3 hours of hospital admission, and the window for meaningful intervention is therefore extremely small. Resuscitative efforts during active bleeding should focus on maintaining haemostatic function with blood product transfusion and early administration of tranexamic acid. Achieving control of haemorrhage is the overarching treatment priority and may require temporising measures before definitive surgical or radiological intervention. This review summarizes the contemporary approaches to resuscitation of bleeding trauma patients, options for achieving haemorrhage control, and current areas of active research including organ protective resuscitation and suspended animation.

Aims and ObjectivesTraumatic brain injury is suspected of inducing coagulopathy but the evidence to support this is conflicting. Systemic analyses in isolated TBI (ITBI) have not consistently demonstrated a functional coagulation deficit. While guidelines recognise the need to emergently reverse anticoagulant therapy, no guideline recommends routine coagulation testing in ITBI, and there are no published algorithms for treatment of any ITBI associated coagulopathy.We hypothesized that there is a specific coagulopathy of ITBI, detectable using functional coagulation tests and that coagulopathy is associated with worse outcomes including raised intracranial pressure (ICP), progression of intracranial haemorrhage (PICH), and mortality.Method and DesignWe retrospectively analysed admission laboratory and ROTEM tests from patients with ITBI (head Abbreviated Injury Score of 3 or more and below 3 in all other body regions) who were enrolled in the prospective observational Activation of Coagulation and Inflammation in Trauma study (REC 07/Q0603/2). Basal cistern compression (BCC) was considered a surrogate for raised intracranial pressure. Results and Conclusion237 patients had a severe ITBI. At least one coagulation abnormality was present in 66% of individuals EXTEM CA5<40mm (45%), EXTEM ML<5% (44%), d-dimer>30,000 (38%), fibrinogen<2g/L (38%) and EXTEM CT>80s (29%), aPTT (7%). Coagulation abnormalities were more common in those with more severe injuries, head AIS 5 versus AIS 3 (70% vs 62%) and BCC (81% vs 64%). The presence of any abnormality was associated with BCC (35% vs 18%), 7-day PICH (67% vs 51%) and higher 7-day mortality (21% vs 7.5%). Several admission tests were good or excellent predictors of BCC (d-dimer AUROC 0.832, fibrinogen AUROC 0.745) and 7-day mortality (aPTT AUROC 0.781, FIBTEM CT AUROC 0.717).Admission ITBI coagulopathy is common and associated with head injury severity and radiological evidence of BCC. The presence of admission coagulopathy was predictive of mortality and basal cistern compression.

This review summarizes the evolution of trauma resuscitation from a one-size-fits-all approach to one tailored to patient physiology. The most dramatic change is in the management of actively bleeding patients, with a balanced blood product–based resuscitation approach (avoiding crystalloids) and surgery focused on hemorrhage control, not definitive care. When hemostasis has been achieved, definitive resuscitation to restore organ perfusion is initiated. This approach is associated with decreased mortality, reduced duration of stay, improved coagulation profile, and reduced crystalloid/vasopressor use. This article focuses on the tools and methods used for trauma resuscitation in the acute phase of trauma care.

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ABO group alters coagulation profiles in the general population and may influence outcomes after trauma. The relationship between trauma-induced coagulopathy, severe injury with haemorrhagic shock, and survival with respect to ABO group is unknown.

Conventional clotting tests are not expeditious enough to allow timely targeted interventions in trauma, and current point-of-care analyzers such as rotational thromboelastometry (ROTEM) have limited sensitivity for hyperfibrinolysis and hypofibrinogenemia.

There has been an increased interest in the use of viscoelastic testing to guide blood product replacement during the acute resuscitation of the injured patient. Currently, no uniformly accepted guidelines exist for how this technology should be integrated into clinical care. In September 2014, an international multidisciplinary group of leaders in the field of trauma coagulopathy and resuscitation was assembled for a 2-day consensus conference in Philadelphia, Pennsylvania. This panel included trauma surgeons, hematologists, blood bank specialists, anesthesiologists, and the lay public.

The Trauma Hemostasis and Oxygenation Research Network held its third annual Remote Damage Control Resuscitation Symposium in June 2013 in Bergen, Norway. The Trauma Hemostasis and Oxygenation Research Network is a multidisciplinary group of investigators with a common interest in improving outcomes and safety in patients with severe traumatic injury. The network’s mission is to reduce the risk of morbidity and mortality from traumatic hemorrhagic shock, in the prehospital phase of resuscitation through research, education, and training. The concept of remote damage control resuscitation is in its infancy, and there is a significant amount of work that needs to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The prehospital phase of resuscitation is critical in these patients. If shock and coagulopathy can be rapidly identified and minimized before hospital admission, this will very likely reduce morbidity and mortality. This position statement begins to standardize the terms used, provides an acceptable range of therapeutic options, and identifies the major knowledge gaps in the field.

Infection following severe injury is common and has a major impact on patient outcomes. The relationship between patient, injury, and physiologic characteristics with subsequent infections is not clearly defined. The objective of this study was to characterize the drivers and burden of all-cause infection in critical care trauma patients.

Trauma hemorrhage continues to carry a high mortality rate despite changes in modern practice. Traditional approaches to the massively bleeding patient have been shown to result in persistent coagulopathy, bleeding, and poor outcomes. Hemostatic (or damage control) resuscitation developed from the discovery of acute traumatic coagulopathy and increased recognition of the negative consequences of dilutional coagulopathy. These strategies concentrate on early delivery of coagulation therapy combined with permissive hypotension. The efficacy of hemostatic resuscitation in correcting coagulopathy and restoring tissue perfusion during acute hemorrhage has not been studied.

Clinical evidence supports the existence of a trauma-induced secondary cardiac injury. Experimental research suggests inflammation as a possible mechanism. The study aimed to determine if there was an early association between inflammation and secondary cardiac injury in trauma patients.

Infection following trauma is associated with increased morbidity and mortality and is common following severe hemorrhage. There is a strong interaction between the coagulation and immunity. The objective of this study was to establish if there was an association between changes in coagulation status after hemorrhage and the subsequent incidence of infection.

Recent therapeutic and observational studies have demonstrated improved survival with better management of haemostasis early after injury. This review delineates our current understanding of the clinical importance, aetiology and pathophysiology of acute traumatic coagulopathy (ATC).

Damage control resuscitation targets acute traumatic coagulopathy with the early administration of high-dose fresh frozen plasma (FFP). FFP is administered empirically and as a ratio with the number of packed red blood cells (PRBC). There is controversy over the optimal FFP:PRBC ratio with respect to outcomes, and their hemostatic effects have not been studied. We report preliminary findings on the effects of different FFP:PRBC ratios on coagulation.

Trauma-induced coagulopathy results from a complex interplay between shock resuscitation and impaired clotting protease function. A pathophysiological role of platelets in this condition remains as yet undefined. This review examines our current knowledge of platelet function in haemostasis, possible mechanisms for aberrant activity in trauma and the role of platelet transfusions in exsanguinating haemorrhage.

BackgroundThe potential of AI systems to support pre-hospital clinical decision-making in both military and civilian settings is significant. However, whilst such algorithms are increasingly available, far less attention has been paid to understanding the impact of such systems on clinical performance. This study had two aims; first, to compare the performance of expert clinicians againstan AI system in a real-world clinical setting and second, to assess the impact of augmenting expert clinical prediction withan AI system.MethodsTwo civilian UK Air Ambulances were selected as surrogate settings relevant to military practice. We performed a prospective study over a six-month period where expert pre-hospital clinicians’ judgement of the risk of Trauma Induced Coagulopathy (TIC) in injured patients was assessed and compared to the performance of an AI system. Two TIC risk predictions were generated for every patient: an AI prediction and a human prediction. Measures of predictive performance included discrimination, calibration, and overall accuracy.ResultsOverall, 51 expert clinicians were enrolled in the study providing 184 patient interactions for analysis. The studied patients had a median age of 31 (range 16, 89), median injury severity score of 17 (IQR 9, 34), 75% were male, and 19% developed TIC.Aim 1:The AI system performed better than clinicians; higher discrimination [AUROC 0.87 (0.79, 0.95) versus 0.83 (0.74, 0.92)] better calibration [0.37 (-0.14, 0.89) versus -1.19 (-1.73, -0.65)] and more accurate [Brier Skill Score 0.34 (0.19, 0.48) versus 0.00 (-0.41, 0.30)].Aim 2:Risk prediction was better in all performance metrics when clinicians were assisted with the AI system [AUROC 0.88 (0.80, 0.95) versus 0.83 (0.74, 0.92)]ConclusionsAI systems can improve human risk prediction in the pre-hospital setting. In the military environment, where austerity and lack of senior clinical expertise may affect outcomes, the benefit of implementing predictive AI should be substantial.(*awarded First Place)

Acute coagulopathy of trauma has only been described relatively recently. Developing early in the postinjury phase, it is associated with increased transfusion requirements and poor outcomes. This review examines the possible initiators, mechanism and clinical importance of acute coagulopathy.

This article will give an overview of abdominal trauma and provide a broad framework for the initial management of injuries to the abdomen. Abdominal injury carries a high morbidity and mortality in all age groups, therefore a sound understanding of the patterns of injury, examination, investigations and resuscitation procedures is vital to the trauma surgeon's armamentarium.

An interview with triple Olympian and 2006 Commonwealth 200 meter freestyle champion Ross Davenport is presented. Topics include the thing he wants to change, his favourite film and book and the biggest lesson he has learned in life. Also tacked is his favourite way of relaxation and his goal to raise a lot of money for a charity before he dies.

A personal narrative is presented which explores the author's five-day activities as a swimmer in Great Britain.

Tranexamic acid (TXA) in traumatic haemorrhage reduces death from bleeding. However, its effect on the coagulation system after trauma is unclear. We aimed to assess the effect of TXA on functional clotting dynamics in patients with suspected traumatic haemorrhage.

The massive-transfusion concept was introduced to recognize the dilutional complications resulting from large volumes of packed red blood cells (PRBCs). Definitions of massive transfusion vary and lack supporting clinical evidence. Damage-control resuscitation regimens of modern trauma care are targeted to the early correction of acute traumatic coagulopathy. The aim of this study was to identify a clinically relevant definition of trauma massive transfusion based on clinical outcomes. We also examined whether the concept was useful in that early prediction of massive transfusion requirements could allow early activation of blood bank protocols.