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Background: Civilian acute trauma care has advanced in recent decades; however, traumatic injury remains the leading cause of death in individuals aged 15 to 29 years in the United States and worldwide. Uncontrolled hemorrhage is the leading preventable cause of death in trauma patients, with up to half of these deaths occurring before reaching a medical facility. The timely application of hemorrhage control measures is critical to enhance the survivability of trauma patients and is one of the major challenges faced by medical providers in austere environments. The purpose of this review is to explore if early resuscitation with cold-stored whole blood therapy reduces the need for component therapy in the first 24 hours postinjury in the civilian population., Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic literature search in Medline, EMBASE, and Transfusion Evidence Library for studies reporting data on 24-hour blood product usage in trauma patients in hemorrhagic shock receiving initial therapy with whole blood. Two reviewers independently performed the selection of eligible studies., Results: Of a total of 2,150 identified studies, 11 studies (n = 4,792) met the inclusion criteria. There was heterogeneity in the study design, interventions, and outcomes. Seven studies reported a statistically significant decrease in 24-hour transfusion requirements in the whole blood intervention group in comparison with the control component therapy group. Three studies reported no significant difference between the two groups. One of the studies reported an increase in 24-hour transfusion requirements in the whole blood group., Conclusion: Overall, there appears to be a decrease in component therapy use following initial resuscitation with whole blood in trauma patients with hemorrhagic shock. However, further research is needed to address this important practical question (PROSPERO registration no. CRD42023422173)., Level of Evidence: Systematic Review; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

SummaryThis article highlights the crucial role of blood transfusion in trauma care and explores the historical and contemporary use of whole blood and freeze-dried plasma in Canadian health care. Early use of whole blood and freeze-dried plasma during global conflicts led to advancements in transfusion medicine. The transition to blood component therapy improved transfusion safety and precision. However, there is an increasing interest in using whole blood and freeze-dried plasma, supported by recent evidence suggesting potential benefits over blood component therapy, particularly in trauma cases. Canadian initiatives, such as leukoreduced whole blood production for the military, indicate efforts to address logistical challenges in delivering trauma care, especially in remote areas. Challenges remain, including logistical issues and regulatory complexities, requiring coordinated efforts for effective implementation. Overall, there's growing support for integrating whole blood and freeze-dried plasma into trauma care across Canada., Competing Interests: Competing interests:: None declared., (© 2024 CMA Impact Inc. or its licensors.)

Abstract: Whole blood can be ABO-type specific (type-specific whole blood (TSWB)) or low-titer O universal donor (low-titer O whole blood (LTOWB)). Having previously used LTOWB, the US Armed Forces Blood Program began using TSWB in 1965 as a method of increasing the donor pool. In contrast to military practice, the Association for the Advancement of Blood and Biotherapies formerly the American association of blood banks (AABB), from its first guidelines in 1958 until 2018, permitted only TSWB. Attempting to reduce time to transfusion, the US military reintroduced LTOWB in the deployed environment in 2015; this practice was endorsed by the AABB in 2018 and is progressively being implemented by military and civilian providers worldwide. Low-titer O whole blood is the only practical solution prehospital. However, there are several reasons to retain the option of TSWB in hospitals with a laboratory. These include (1) as-yet ill-defined risks of immunological complications from ABO-incompatible plasma (even when this has low titers of anti-A and -B), (2) risks of high volumes of LTOWB including published historical advice (based on clinical experience) not to transfuse type-specific blood for 2 to 3 weeks following a substantial LTOWB transfusion, (3) uncertainty as to the optimal definition of "low titer," and (4) expanding the potential donor pool by allowing type-specific transfusion. Several large randomized controlled trials currently underway are comparing LTOWB with component therapy, but none address the question of LTOWB versus TSWB. There are sufficient data to suggest that the additional risks of transfusing LTOWB to non-group O recipients should be avoided by using TSWB as soon as possible. Combined with the advantage of maintaining an adequate supply of blood products in times of high demand, this suggests that retaining TSWB within the civilian and military blood supply system is desirable. TSWB should be preferred when patient blood group is confirmed in facilities with a hematology laboratory, with LTOWB reserved for patients whose blood group is unknown., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Major traumatic hemorrhage is now frequently treated by early hemostatic resuscitation on hospital arrival. Prehospital hemostatic resuscitation could therefore improve outcomes for bleeding trauma patients, but there are logistical challenges. Freeze-dried plasma (FDP) offers indisputable logistical advantages over conventional blood products, such as long shelf life, stability at ambient temperature, and rapid reconstitution without specialized equipment. We sought high level, randomized, controlled evidence of FDP clinical efficacy in trauma. A structured systematic search of MEDLINE/PubMed was carried out and identified 52 relevant English language publications. Three studies involving 607 patients met our criteria: Resuscitation with Blood Products in Patients with Trauma-related Hemorrhagic Shock receiving Prehospital Care (RePHILL, n = 501); Prehospital Lyophilized Plasma Transfusion for Trauma-Induced Coagulopathy in Patients at Risk for Hemorrhagic Shock (PREHO-PLYO, n = 150); and a pilot Australian trial (n = 25). RePHILL found no effect of FDP plus packed red blood cells (PRBC) concentrate transfusion versus saline on mortality. PREHO-PLYO found no effect of FDP versus saline on International Normalized Ratio (INR) at hospital arrival. The pilot trial found that study of PRBC versus PRBC plus FDP was feasible during long air transport times to an Australian trauma centre. Further research is required to determine under what conditions FDP might provide prehospital benefit to trauma patients., Competing Interests: Declaration of Competing Interest The authors declare that no relevant conflicts of interest exist., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Trauma team leaders (TTLs) have traditionally been general surgeons; however, some trauma centres use a mixed model of care where both surgeons and non-surgeons (primarily emergency physicians) perform this role. The objective of this multicentre study was to provide a well-powered study to determine if TTL specialty is associated with mortality among major trauma patients., Methods: Data were collected from provincial trauma registries at six level 1 trauma centres across Canada over a 10-year period. We included adult trauma patients (age ≥ 18 yrs) who triggered the highest-level trauma activation. The primary outcome was the difference in risk-adjusted in-hospital mortality for trauma patients receiving initial care from a surgeon versus a non-surgeon TTL., Results: Overall, 12,961 major trauma patients were included in the analysis. Initial treatment was provided by a surgeon TTL in 57.8% (n = 7513) of cases, while 42.2% (n = 5448) of patients were treated by a non-surgeon TTL. Unadjusted mortality occurred in 11.6% of patients in the surgeon TTL group and 12.7% of patients in the non-surgeon TTL group (OR 0.87, 95% CI 0.78-0.98, p = 0.02). Risk-adjusted mortality was not significantly different between patients cared for by surgeon and non-surgeon TTLs (OR 0.92, 95% CI 0.80-1.06, p = 0.23). Furthermore, we did not observe differences in risk-adjusted mortality for any of the subgroups evaluated., Conclusions: After risk adjustment, there was no difference in mortality between trauma patients treated by surgeon or non-surgeon TTLs. Our study supports emergency physicians performing the role of TTL at level 1 trauma centres., (© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Importance: The most common cause of preventable death on the conventional battlefield or on special operations force (SOF) missions is hemorrhage. SOF missions may take place in remote and austere locations. Many preventable deaths in combat occur within 30 min of wounding. Therefore, SOF damage control resuscitation (DCR) and damage control surgery (DCS) teams may improve combat casualty survival in the SOF environment., Objective: To determine the effect of SOF DCR and DCS teams on combat casualty survival. Also, to describe commonalities in team structure, logistics, and blood product usage., Design: A narrative review of the English literature used a Medline and Embase search strategy. The authors were contacted for more details as required. The risk of bias was assessed using the Cochrane Collaboration's ROBINS-I tool. Pooling of data was not done to the heterogeneity of studies., Results: Weak evidence was identified showing a clinical benefit of SOF DCR and DCS teams. Conflicting evidence from less rigorous studies was also found. The overall risk of bias using ROBINS-I was serious to critical. Several commonalities in team structure, training, and logistics were found., Conclusions and Relevance: There is conflicting evidence regarding the effect SOF DCR and DCS teams have on combat casualty survival. There is no strong evidence that SOF DCR and DCS teams cause harm. More robust data collection is recommended to evaluate these teams., (© 2022 AABB.)

Background: Coagulopathic bleeding is frequently present after major trauma. However, trauma-induced coagulopathy (TIC) remains incompletely understood. This laboratory analysis of blood samples derived from our completed trial on fibrinogen in the initial resuscitation of severe trauma (FiiRST) was conducted to evaluate TIC and associated responses to fibrinogen replacement., Study Design and Methods: We conducted a retrospective evaluation of TIC in 45 FiiRST trial patients based on rotational thromboelastometry (ROTEM), international normalized ratio (INR), and biomarkers for hemostasis and endotheliopathy. Whole blood was analyzed by ROTEM. Plasma was analyzed for INR and biomarkers., Results: Overall, 19.0% and 30.0% of the FiiRST trial patients were coagulopathic on admission defined by EXTEM maximum clot firmness out of the range of 40-71 mm and INR >1.2, respectively. The FiiRST patients showed lower fibrinogen, factor II and V levels, protein C and antiplasmin activities, higher activated protein C, tissue plasminogen activator, d-dimer, and thrombomodulin concentrations at admission than healthy controls. Most of the biomarkers changed their activities during 48-h hospitalization, but were at abnormal levels even 48-h after admission. The fibrinogen treatment reduced hypofibrinogenemia and increased factor XIII level, but had no significant effects on other biomarkers levels. Limited development of endotheliopathy was indicated by syndean-1, thrombomodulin, and sE-selectin., Conclusions: About 19%-30% of the trauma patients in the FiiRST trial were coagulopathic on hospital admission depending on the definition of TIC. Analyses of the TIC biomarkers demonstrated that hemostasis would not return to normal after 48-h hospitalization, and fibrinogen replacement improved hypofibrinogenemia., (© 2021 Her Majesty the Queen in Right of Canada. Transfusion © 2021 AABB. Reproduced with the permission of the Minister of Natural Defence Canada.)

Background: Treatment of acute trauma coagulopathy has shifted toward rapid replacement of coagulation factors with frozen plasma (FP). There are logistic difficulties in providing FP. Freeze-dried plasma (FDP) may have logistical advantages including easier storage and rapid preparation time. This review assesses the feasibility, efficacy, and safety of FDP in trauma., Study Design and Methods: Studies were searched from Medline, Embase, Cochrane Controlled Trials Register, ClinicalTrials.gov, and Google Scholar. Observational and randomized controlled trials (RCTs) assessing FDP use in trauma were included. Trauma animal models addressing FDP use were also included. Bias was assessed using validated tools. Primary outcome was efficacy, and secondary outcomes were feasibility and safety. Meta-analyses were conducted using random-effect models. Evidence was graded using Grading of Recommendations Assessment, Development, and Evaluation profile., Results: Twelve human studies (RCT, 1; observational, 11) and 15 animal studies were included. Overall, studies demonstrated moderate risk of bias. Data from two studies (n = 119) were combined for meta-analyses for mortality and transfusion of allogeneic blood products (ABPs). For both outcomes, no difference was identified. For mortality, pooled odds ratio was 0.66 (95% confidence interval, 0.29-1.49), with I2 = 0%. Use of FDP is feasible, and no adverse events were reported. Animal data suggest similar results for coagulation and anti-inflammatory profiles for FP and FDP., Conclusion: Human data assessing FDP use in trauma report no difference in mortality and transfusion of ABPs in patients receiving FDP compared with FP. Data from animal trauma studies report no difference in coagulation factor and anti-inflammatory profiles between FP and FDP. Results should be interpreted with caution because most studies were observational and have heterogeneous population (military and civilian trauma) and a moderate risk of bias. Well-designed prospective observational studies or, preferentially, RCTs are warranted to answer FDP's effect on laboratory (coagulation factor levels), transfusion (number of ABPs), and clinical outcomes (organ dysfunction, length of stay, and mortality)., Level of Evidence: Systematic review and meta-analysis, level IV., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Road traffic injuries (RTIs) are increasingly being recognized for their significant economic impact. Mozambique, like other low-income countries, suffers staggering rates of road traffic collisions. To our knowledge, this is the first study to estimate direct hospital costs of RTIs using a bottom-up, micro-costing approach in the Mozambican context. This study aims to calculate the direct, inpatient costs of RTIs in Mozambique and compare it to the financial capacity of the Mozambican public health care system., Methods: This was a retrospective, single-centre study. Charts of all patients with RTIs admitted to Maputo Central Hospital over a period of 2 months were reviewed. The costs were recorded and analysed based on direct costs, human resource costs, and overhead costs. Costs were calculated using a micro-costing approach., Results: In total, 114 patients were admitted and treated for RTIs at Maputo Central Hospital during June-July 2015. On average, the hospital cost per patient was US$ 604.28 (IQR 1033.58). Of this, 44% was related to procedural costs, 23% to diagnostic imaging costs, 17% to length-of-stay costs, 9% to medication costs, and 7% to laboratory test costs. The average annual inpatient cost of RTIs in Mozambique was almost US$ 116 million (0.8% of GDP)., Conclusion: The financial burden of RTIs in Mozambique represents approximately 40% of the annual public health care budget. These results help highlight the economic impact of trauma in Mozambique and the importance of an organized trauma system to reduce such costs.

Background: Both thrombelastography (TEG) and rotational thromboelastometry (ROTEM) have been investigated for diagnosis of coagulopathy and guidance of resuscitation in trauma and surgery. Given similarities between the two systems, it is important to determine whether one is superior to the other and how comparable they are to conventional coagulation tests (CCTs). Therefore, we conducted a comparative study of functional fibrinogen and coagulation assays using TEG and ROTEM and CCTs to determine their capability to monitor coagulation profiles, diagnose coagulopathy and predict blood transfusion requirements in trauma patients., Methods: Blood samples were collected from 45 patients at admission and during 48-h hospitalization as part of a randomized control trial on early fibrinogen replacement in trauma. Functional fibrinogen (FF) TEG, ROTEM FIBTEM and EXTEM, and CCTs were performed and compared., Results: We found significant differences between the placebo and fibrinogen groups over hospitalization time in FF TEG MA, ROTEM CT, MCF and LI30. FF TEG MA and ROTEM FIBTEM MCF mirrored plasma fibrinogen profiles, reached a maximum difference between the two groups 1-3 h after fibrinogen administration. In comparison, CCTs detected minimal hemostatic changes by fibrinogen treatment. TEG and ROTEM showed various degrees of correlations with CCTs. TEG MA and ROTEM MCF provided better predictions for plasma and RBC transfusions than CCTs, but poor accuracy for cryoprecipitate transfusion. Both TEG and ROTEM well predicted hypofibrinogenemia (fibrinogen concentration < 1 g/L), but poorly detected coagulopathy (INR ≥ 1.2)., Conclusions: TEG and ROTEM detected increases in clot strength following early use of fibrinogen. ROTEM also detected changes in coagulation time and clot lysis. Both were better than CCTs for monitoring coagulation profiles and predicting transfusion requirements., (Crown Copyright © 2019. Published by Elsevier B.V. All rights reserved.)

Introduction: Tactical Combat Casualty Care (TCCC) training imposes psychophysiological stress on medics. It is unclear whether these stress levels vary with the training modalities selected. It is also unclear how stress levels could have an impact on medical performance and skill uptake., Materials and Methods: We conducted a pilot study to compare the effects of live tissue (LT) with a high-fidelity patient simulator (SIM) on the level of stress elicited, performance, and skill uptake during battlefield trauma training course in an operating room (OR) and in a simulated battlefield scenario (field). In the report, we studied the effects of training modalities and their changes on stress levels by measuring different biomarkers (salivary amylase, plasma catecholamines, and neuropeptide Y) at various time points during the trauma training course., Results: We found that the training resulted in significant psychophysiological stress as indicated by elevated levels of various biomarkers relative to baseline immediately after both OR and field assessment (p < 0.05). Compared with pre-OR levels, the LT training in the OR resulted in significant increases in the plasma levels of epinephrine, norepinephrine, and neuropeptide (p = 0.013, 0.023, 0.004, respectively), whereas the SIM training in the OR resulted in significant increases in the plasma levels of norepinephrine and neuropeptide (p = 0.003 and 0.008). Compared with pre-field levels, we found significant increases in plasma epinephrine concentration in the SIM group (p = 0.016), plasma norepinephrine concentration in the LT group (p = 0.015), and plasma neuropeptide Y concentration in both LT (p = 0.006) and SIM groups (p = 0.029). No differences in the changes of biomarker levels were found between LT and SIM groups in the OR and field. Compared with pre-field levels, the testing on the same modality as that in the OR in the simulated battlefield resulted in significant increases in norepinephrine and neuropeptide levels (p = 0.013 and 0.015), whereas the testing on different modalities resulted in significant increases in amylase, epinephrine, and neuropeptide levels (p = 0.016, 0.05, 0.018, respectively). There was a significantly larger increase in plasma norepinephrine concentration (p = 0.031) and a trend toward a greater increase in the salivary amylase level (p = 0.052) when the field testing involved a different modality than the OR compared with when OR and field testing involved the same modality. Although most of the biomarkers returned to baseline levels after 24 h, plasma norepinephrine levels remained significantly higher regardless of whether field testing occurred on the same or different modality compared with OR (p = 0.040 and 0.002)., Conclusion: TCCC training led to significant increase in psychophysiological stress, as indicated by elevated levels of various biomarkers. The training modalities did not result in any differences in stress levels, whereas the switch in training modalities appeared to elicit greater stress as evidenced by changes in specific biomarkers (amylase and norepinephrine). A comparative study with a larger sample size is warranted., (© Crown copyright 2018.)

The Trauma Hemostasis and Oxygenation Research (THOR) Network has developed a consensus statement on the role of permissive hypotension in remote damage control resuscitation (RDCR). A summary of the evidence on permissive hypotension follows the THOR Network position on the topic. In RDCR, the burden of time in the care of the patients suffering from noncompressible hemorrhage affects outcomes. Despite the lack of published evidence, and based on clinical experience and expertise, it is the THOR Network's opinion that the increase in prehospital time leads to an increased burden of shock, which poses a greater risk to the patient than the risk of rebleeding due to slightly increased blood pressure, especially when blood products are available as part of prehospital resuscitation.The THOR Network's consensus statement is, "In a casualty with life-threatening hemorrhage, shock should be reversed as soon as possible using a blood-based HR fluid. Whole blood is preferred to blood components. As a part of this HR, the initial systolic blood pressure target should be 100 mm Hg. In RDCR, it is vital for higher echelon care providers to receive a casualty with sufficient physiologic reserve to survive definitive surgical hemostasis and aggressive resuscitation. The combined use of blood-based resuscitation and limiting systolic blood pressure is believed to be effective in promoting hemostasis and reversing shock".

Introduction: The optimum method for training military personnel for combat casualty care is unknown. In particular, there is debate regarding the incremental benefit of live animal tissue training (LTT) over inanimate human patient simulators (HPSs). Although both LTT and HPS are currently used for predeployment training, the efficacy of these models has not been established., Materials and Methods: Canadian Armed Forces combat medics, deployed to Afghanistan between 2006 and 2011, were surveyed retrospectively regarding their experience with combat casualty care and predeployment training. HPSs were used to prepare these combat medics for early rotations. In later years, personnel received a combination of training modalities including HPS and LTT, using anaesthetized porcine models in accordance with appropriate animal care standards. Among those deployed on multiple rotations, there was a cohort who was prepared for deployment using only HPS training, and who later were prepared using mixed-modality training, which included LTT. We asked these medics to compare their predeployment training using HPS only versus their mixed-modality training in how each training package prepared them for battlefield trauma care., Results: Thirty-eight individuals responded, with 20 respondents deployed on multiple rotations. Respondents performed life-saving skills during 89% of the rotations. Self-perceived competence and preparedness were notably higher after incorporation of LTT than after HPS alone. Of 17 respondents deployed on both early and late rotations, the majority felt the latter training was more worthwhile. In addition, almost all individuals felt that LTT should be added to HPS training. Narrative comments described multiple benefits of adding LTT to other types of training., Conclusions: Among many experienced Canadian Armed Forces personnel, LTT is considered essential predeployment preparation. Individuals who experienced only HPS training before active duty on their first combat deployment reported feeling more competent on subsequent combat deployments after the addition of live tissue models., Impact: There has been a movement away from the use of LTT in preparing combat medics for deployment. This article suggests that we should reconsider any decision to completely exclude Live Tissue Training as part of our training plan for combat medics., Recommendations: Military medical organizations should consider judiciously incorporating LTT with human patient simulation training to prepare combat medics for treating battlefield trauma., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Hypothermia is present in up to two-thirds of patients with severe injury, although it is often disregarded during the initial resuscitation. Studies have revealed that hypothermia is associated with mortality in a large percentage of trauma cases when the patient's temperature is below 32 °C. Risk factors include the severity of injury, wet clothing, low transport unit temperature, use of anesthesia, and prolonged surgery. Fortunately, associated coagulation disorders have been shown to completely resolve with aggressive warming. Selected passive and active warming techniques can be applied in damage control resuscitation. While treatment guidelines exist for acidosis and bleeding, there is no evidence-based approach to managing hypothermia in trauma patients. We synthesized a goal-directed algorithm for warming the severely injured patient that can be directly incorporated into current Advanced Trauma Life Support guidelines. This involves the early use of warming blankets and removal of wet clothing in the prehospital phase followed by aggressive rewarming on arrival at the hospital if the patient's injuries require damage control therapy. Future research in hypothermia management should concentrate on applying this treatment algorithm and should evaluate its influence on patient outcomes. This treatment strategy may help to reduce blood loss and improve morbidity and mortality in this population of patients.

Fresh whole blood (FWB) transfusion is an option for providing volume and oxygen carrying capacity to bleeding Special Operations soldiers who are injured in an austere environment and who are far from a regular blood bank. Retrospective data from recent conflicts in Iraq and Afghanistan show an association between the use of FWB and survival. We reviewed the literature to document the issues surrounding FWB transfusion to Special Operations soldiers in the austere environment and surveyed the literature regarding best practice guidelines for and patient outcomes after FWB transfusions. Most literature regarding FWB transfusion is retrospective or historical. There is limited prospective evidence currently to change transfusion practice in tertiary care facilities, but FWB remains an option in the austere setting.

Medical support to deployed field forces is increasingly becoming a shared responsibility among allied nations. National military medical planners face several key challenges, including fiscal restraints, raised expectations of standards of care in the field and a shortage of appropriately trained specialists. Even so, medical services are now in high demand, and the availability of medical support may become the limiting factor that determines how and where combat units can deploy. The influence of medical factors on operational decisions is therefore leading to an increasing requirement for multinational medical solutions. Nations must agree on the common standards that govern the care of the wounded. These standards will always need to take into account increased public expectations regarding the quality of care. The purpose of this article is to both review North Atlantic Treaty Organization (NATO) policies that govern multinational medical missions and to discuss how recent scientific advances in prehospital battlefield care, damage control resuscitation and damage control surgery may inform how countries within NATO choose to organize and deploy their field forces in the future.

Traumatic injury is increasing in importance in all settings and environments worldwide. Many preventable deaths are from conditions that are common and treatable. However, as potentially lethal injuries often induce progressive and frequently irreversible physiologic decline, the timing of interventions is critical. Invasive treatments may need to be offered by prehospital care providers who lack extensive training and practice. Telementoring allows experienced experts to guide less experienced providers remotely using information technology (IT). Early experience has shown that these techniques are practical and considered valuable. Their translation to regular practice, however, will require the immediate availability of appropriately trained remote experts willing to serve as mentors. Acute care trauma specialists are acclimatized to responding to out-of-hospital consultations and assuming overall responsibility for critical physiology and transport and may serve as the backbone of such a national/ international call response initiative.

Background: Exsanguinating haemorrhage is a leading cause of death in severely injured trauma patients. Management includes achieving haemostasis, replacing lost intravascular volume with fluids and blood, and treating coagulopathy. The provision of fluids and blood products is contingent on obtaining adequate vascular access to the patient's venous system. We sought to examine the nature and timing of achieving adequate intravenous (IV) access in trauma patients requiring uncrossmatched blood in the trauma bay., Methods: We performed a retrospective chart review of all patients admitted to our trauma centre from 2005 to 2009 who were transfused uncrossmatched blood in the trauma bay. We examined the impact of IV access on prehospital times and time to first PRBC transfusion., Results: Of 208 study patients, 168 (81%) received prehospital IV access, and the on-scene time for these patients was 5 min longer (16.1 vs 11.4, p<0.01). Time to achieving adequate IV access in those without any prehospital IVs occurred on average 21 min (6.6-30.5) after arrival to the trauma bay. A central venous catheter was placed in 92 (44%) of patients. Time to first blood transfusion correlated most strongly with time to achieving central venous access (Pearson correlation coefficient 0.94, p<0.001) as opposed to time to achieving adequate peripheral IV access (Pearson correlation coefficient 0.19, p=0.12)., Conclusions: We found that most bleeding patients received a prehospital IV; however, we also found that obtaining prehospital IVs was associated with longer EMS on-scene times and longer prehospital times. Interestingly, we found that obtaining a prehospital IV was not associated with more rapid initiation of blood product transfusion. Obtaining optimal IV access and subsequent blood transfusion in severely injured patients continues to present a challenge., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose of Review: This article reviews the latest operative trauma surgery techniques and strategies, which have been published in the last 10 years. Many of the articles we reviewed come directly from combat surgery experience and may be also applied to the severely injured civilian trauma patient and in the context of terrorist attacks on civilian populations., Recent Findings: We reviewed the most important innovations in operative trauma surgery; the use of ultrasound and computed tomography in the preoperative evaluation of the penetrating trauma patient, the use of temporary vascular shunts, the current management of military wounds, the use of preperitoneal packing in pelvic fractures and the management of the multiple traumatic amputation patient., Summary: The last 10 years of conflict has produced a wealth of experience and novel techniques in operative trauma surgery. The articles we review here are essential for the contemporary care of the severely injured trauma patient, whether they are card for in a level 1 trauma center or in a field hospital at the edge of a battlefield.

Objectives: To 1) review the existing evidence for early mobilization of the critically ill patients in the ICU with polytrauma; 2) provide intensivists with an introduction to the biomechanics, physiology, and nomenclature of injuries; 3) summarize the evidence for early mobilization in each anatomic area; and 4) provide recommendations for the mobilization of these patients., Data Sources: A literature search of the MEDLINE and EMBASE databases for articles published in English between 1980 and 2011., Study Selection: Studies pertaining to physical therapy and rehabilitation in trauma patients were selected. Articles were excluded if they dealt with pediatrics, geriatrics, burn injuries, isolated hand injuries, chronic (i.e., not acute) injuries, nontraumatic conditions, and pressure/decubitus ulcers, were in a language other than English, were published only in abstract form, were letters to the editor, were case reports, or were published prior to 1980., Data Extraction: Reviewers extracted data and summarized results according to anatomical areas., Data Synthesis: Of 1,411 titles and abstracts, 103 met inclusion criteria. We found no articles specifically addressing the rehabilitation of polytrauma patients in the ICU setting or patients with polytrauma in general. We summarized the articles addressing the role of mobilization for specific injuries and treatments. We used this evidence, in combination with biologic rationale and physician and surgeon experience and expertise, to summarize the important considerations when providing physical therapy to these patients in the ICU setting., Conclusions: There is a paucity of evidence addressing the role of early mobilization of ICU patients with polytrauma and patients with polytrauma in general. Evidence for the beneficial role of early mobilization of specific injuries exists. Important considerations when applying a strategy of early physical therapy and mobilization to this distinctive patient group are summarized.