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Journal Watch

OpMed Journal Watch October 2019

Journal list collected via Google Scholar watch list for new articles, citations, and related research of the following people: R Kotwal, A Fisher, J Kragh, M Schreiber, S Schauer, T Rasmussen, K Brohi, J Holcomb, R Mabry, B Eastridge, S Shackelford, F Butler.

Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System

Gauss T, Ageron F, Devaud M, et al. Association of Prehospital Time to In-Hospital Trauma Mortality in a Physician-Staffed Emergency Medicine System. JAMA Surg. Published online September 25, 2019. doi:https://doi.org/10.1001/jamasurg.2019.3475

Findings  The results of this cohort study from 2 French trauma registries demonstrate a linear association between total prehospital time and in-hospital all-cause mortality. The odds of death increased by 8% for each 10-minute increase in prehospital time. These findings call for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.

Prospective cohort study examining the use of regional anesthesia for early pain management after combat-related extremity injury

Gallagher RM, Polomano RC, Giordano NA, et al. Prospective cohort study examining the use of regional anesthesia for early pain management after combat-related extremity injury. Regional Anesthesia & Pain Medicine Published Online First: 27 September 2019. doi:  https://doi.org/10.1136/rapm-2019-100773

Conclusion Findings indicate that when administered soon after traumatic injury, regional anesthesia is a valuable pain management intervention. Future longitudinal studies investigating the timely delivery of regional anesthesia for optimal pain management in civilian trauma settings are needed.

Risk Associated With Autologous Fresh Whole Blood Training

Donham B, Barbee GA, Deaton TG, Kerr W, Wier RP, Fisher AD. Risk Associated With Autologous Fresh Whole Blood Training. J Spec Op Med. 2019 Fall;19(3):24-25. (https://www.ncbi.nlm.nih.gov/pubmed/31539430)

Fresh whole blood (FWB) is increasingly being recognized as the ideal resuscitative fluid for hemorrhagic shock. Because of this, military units are working to establish the capability to give FWB from a walking blood bank donor in environments that are unsupported by conventional blood bank services. Therefore, many military units are performing autologous blood transfusion training. In this training, a volunteer has a unit of blood collected and then transfused back into the same donor. The authors report their experience performing an estimated 3408 autologous transfusions in training and report no instances of hemolytic transfusion reactions or other major complications. With appropriate control measures in place, autologous FWB training is low-risk training.

Surgery in Traumatic Injury and Perioperative Considerations

Curry N, Brohi K. Surgery in Traumatic Injury and Perioperative Considerations. Semin Thromb Hemost. doi: 10.1055/s-0039-1697932 (link)

A severely injured patient presents several unique challenges to an admitting trauma team. Not only must the extent of the patient’s injuries, particularly those that are life-threatening, be determined within minutes of hospital arrival, but also the trauma team needs to be able to assess whether the patient is bleeding and/or has an attendant coagulopathy. Early management of trauma patients is dictated by the presence (or absence) of significant bleeding. Standard definitive surgical procedures can be conducted in hemodynamically stable patients, but those in hemorrhagic shock should be treated according to damage control resuscitation (DCR) principles. DCR is a practice that has evolved over the last two to three decades, combining limited surgical techniques, which provide early hemorrhage control, and balanced transfusion resuscitation strategies, which mitigate (and ideally) treat trauma-induced coagulopathy (TIC). This review describes the contemporary perioperative management of trauma patients who have significant bleeding and/or TIC and sets out the evidence around the current approach for hemostatic resuscitation in these patients.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in a swine model of hemorrhagic shock and blunt thoracic injury

Beyer, C.A., Hoareau, G.L., Kashtan, H.W. et al. Eur J Trauma Emerg Surg (2019). https://doi.org/10.1007/s00068-019-01185-3

Conclusions Thoracic trauma blunted the proximal arterial pressure augmentation during REBOA but had minimal impacts on resuscitative outcomes. This initial study indicates that REBOA does not seem to exacerbate pulmonary contusion in swine, but blunt thoracic injuries may attenuate the expected rises in proximal blood pressure during REBOA.

Intraosseous needles in pediatric cadavers: Rate of malposition

Maxien D, Wirth S, Peschel O, et al. Intraosseous needles in pediatric cadavers: Rate of malposition. Resuscitation. 2019;145:1-7 https://doi.org/10.1016/j.resuscitation.2019.09.028

Conclusion. Our study showed relatively high malposition rates for ION devices in pediatric cadavers which was not to be assumed regarding the success rates of 80% and higher in previous literature. This should be clarified by further studies in living patients.

Freeze‐dried plasma stability under prehospital field conditions

Zur, M. , Glassberg, E. , Gorenbein, P. , Epstein, E. , Eisenkraft, A. , Misgav, M. and Avramovich, E. (2019), Freeze‐dried plasma stability under prehospital field conditions. Transfusion, 59: 3485-3490. doi:10.1111/trf.15533

Conclusion Our data show minimal decreases in clotting factors in FDP after storage under field conditions, when compared to laboratory normal ranges. Along with the many advantages of FDP, this supports its use at the point of injury under battlefield conditions, despite uncontrolled storage environments. Under controlled storage conditions at 4°C, shelf life could possibly be extended, although further study is required.

Novel self-fixation chest drain device tested in a swine model of pneumo-hemothorax

Arik Eisenkraft, Lilach Gavish, Linn Wagnert-Avraham, S. David Gertz, Iris Milner, Ruth Shaylor, David Kushnir, Asaf Kedar & Yoav Mintz (2019) Novel self-fixation chest drain device tested in a swine model of pneumo-hemothorax, Minimally Invasive Therapy & Allied Technologies, DOI: 10.1080/13645706.2019.1671456

Results: The insertion of the device was simple and effective without detectable negative physiological effects. Reliable fixation was achieved without difficulty. Air and liquid were promptly drained from the chest cavity. Minimal tissue laceration occurred when applying the device in a scenario of erroneous pneumothorax diagnosis with fully expanded lungs. Interconnection with other surgical accessories was smooth.
Conclusion: The C-Lant is a novel device that facilitates easy insertion and fixation of chest-tubes by minimally experienced medical providers and reduces the likelihood of unwanted expulsion. Clinical studies are planned.

Effect of tranexamic acid administration on acute traumatic coagulopathy in rats with polytrauma and hemorrhage

Wu X, Benov A, Darlington DN, Keesee JD, Liu B, et al. (2019) Effect of tranexamic acid administration on acute traumatic coagulopathy in rats with polytrauma and hemorrhage. PLOS ONE 14(10): e0223406. https://doi.org/10.1371/journal.pone.0223406

The data show that in rats, limited FWB resuscitation restores hemodynamic function but does not completely correct ATC, and administration of TXA within simulated prehospital time frame (45min after trauma) followed by limited FWB resuscitation is not capable of correction of established systemic ATC by preventing the elevation of PT, but rather may improve overall outcomes of FWB resuscitation by attenuation of acute lung injury, as characterized by a reduction in vascular permeability and leukocytes infiltration. TXA given prior to trauma reduced levels of fibrinolysis at the site of tissue injury and circulatory d-dimer levels, and delayed development of coagulopathy independent of reduction of fibrinogen levels following trauma, which explains the effectiveness of TXA given prior to elective surgery in reducing bleeding but does not fully explain the observed clinical benefit in trauma patients. However, this study suggests that, without any other intervention, a single dose of TXA administered immediately at the point of injury is thought to be capable of inhibition of fibrinolysis in the clot, which is considered beneficial in reducing bleeding from acute surgical procedures after trauma. On the other hand, the reductions in observed biomarkers of tissue injury in this study and others suggest that, at least within one hour timeframe observed in CRASH-2 and in this rodent study, TXA may provide clinical benefit through mechanisms other than simply clot stabilization.

Progress on combat damage control resuscitation/surgery and its application in the Chinese People’s Liberation Army

Chen S, Yang J, Zhang L, et al. Progress on combat damage control resuscitation/surgery and its application in the Chinese People’s Liberation Army. Journal of Trauma and Acute Care Surgery. 2019;87(4):954-960. doi: 10.1097/TA.0000000000002344

ABSTRACT Damage control resuscitation (DCR) and damage control surgery (DCS) has now been developed as a well-established standard of care for severely injured civilian patients worldwide. On the other hand, the application of combat DCR/DCS has saved the lives of thousands of severely injured casualties in several wars during the last two decades. This article describes the great progress on DCR/DCS in the last two decades and its application in the Chinese People’s Liberation Army (PLA). The main development of the advanced theories of combat DCR/DCS including the global integration of DCR/DCS, application of remote battlefield DCR, balanced hemostatic resuscitation in combat hospitals and enhancement of en route DCR. There are two key factors that determine the feasibility of combat DCR: one is the availability of resources and supplies to implement the advanced theories of combat DCR/DCS, the other is the availability of qualified personnel who master the skills needed for the implementation of DCR/DCS. In the PLA, the advanced theories of combat DCR/DCS have now been widely accepted, and some of related advanced products, such as fresh-frozen plasma, packed red blood cells, and platelets, have been available in Level III medical facilities. In conclusion, great progress in combat DCR/DCS has been achieved in recent years, and the Chinese PLA is keeping good pace with this development, although there is still room for improvement.

Transition from abdominal aortic and junctional tourniquet to zone 3 resuscitative endovascular balloon occlusion of the aorta is feasible with hemodynamic support after porcine class IV hemorrhage

Brännström A, Dahlquist A, Gustavsson J, et al. Transition from abdominal aortic and junctional tourniquet to zone 3 resuscitative endovascular balloon occlusion of the aorta is feasible with hemodynamic support after porcine class IV hemorrhage. Journal of Trauma and Acute Care Surgery. 2019;87(4):849-855. doi: 10.1097/TA.0000000000002426

RESULTS Transition from AAJT to zone 3 REBOA caused a significant decrease in mean arterial pressure (25 mm Hg). Hemostasis was maintained. The common femoral artery diameter decreased by 1.8 mm (38%) after hemorrhage and further 0.7 mm (23%) after aortic occlusion.
CONCLUSION Transition from AAJT to zone 3 REBOA after a class IV bleeding is feasible with hemodynamic support. Vascular access to the femoral artery for REBOA insertion poses a technical challenge after hemorrhage and AAJT application.

Testing of novel spectral device sensor in swine model of airway obstruction

Blackburn MB, Nawn CD, Ryan KL. Testing of novel spectral device sensor in swine model of airway obstruction. Physiological Reports. 2019;7(19) e14246, https://doi.org/10.14814/phy2.14246 (PDF)

Loss of a patent airway is a significant cause of prehospital death. Endotracheal intubation is the gold standard of care but has a high rate of failure and complications, making development of new devices vital. We previously showed that tracheal tissue has a unique spectral profile which could be utilized to confirm correct airway device placement. Therefore, the goals of this study were twofold: 1- to develop an airway obstruction model and 2- use that model to assess how airway compromise affects tissue reflectance. Female swine were anesthetized, intubated, and instrumented. Pigs were allowed to breathe spontaneously and underwent either slow- or rapid-onset obstruction until a real-time pulse oximeter reading of ≤50%. At baseline, 25%, 50%, 75%, and 100% obstruction, a fiber-optic reflection probe was inserted into the trachea and esophagus to capture reflectance spectra. Both slow- and rapid-onset obstruction significantly decreased arterial oxygen concentration (sO2) and increased partial pressure of CO2 (pCO2). The presence of the tracheal-defining spectral profile was confirmed and remained consistent despite changes in sO2 and pCO2. This study validated a model of slow- and rapid airway obstruction that results in significant hypoxia and hypercapnia. This is valuable for future testing of airway device components that may improve airway management. Additionally, our data support the ability of spectral reflectance to differentiate between tracheal and esophageal tissues in the presence of a clinical condition that decreases oxygen saturation.

Tactical combat casualty care in the navy – Challenges and way ahead

Singh M V, Ray S, Goyal S, Singh R J, Sharma R. Tactical combat casualty care in the navy – Challenges and way ahead. J Mar Med Soc 2019;21:105-7 (link)

TCCC has changed battlefield trauma care from basic care for the injured to that developed for injuries in the combat zone. It has helped combat units to achieve unprecedented casualty survival rates with aggressive use of tourniquets when these units trained all of their combatants in these techniques. The Naval battle scenario is different. Blast injuries are common which results in immediate death without giving a chance for survival. The distribution of injuries is mostly bimodal rather than trimodal. However, training on TCCC guidelines is required to be implemented for all personnel before being deployed on board, and the medics should be properly trained in the use of tourniquets, chest tubes, and undertaking cricothyroidotomy. Future work should include epidemiological research on the analysis of injuries onboard. The future development of portable equipment used in medical rescue at sea must be powerful enough to save more people. Equipping all officers and sailors, including the medics with prehospital life-saving skills and successful evacuation of the casualty to a higher medical facility, will be a huge force multiplier in any deployment setting in the navy while at sea.

Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock

Auten JD, McEvoy CS, Roszko PJ, et al. Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock. J Surg Research. 2020;246(1):190-199. doi: https://doi.org/10.1016/j.jss.2019.09.005

Conclusions. Push-Pull conferred the highest flow rates, but with higher infusion pressures and evidence of intravascular hemolysis. Rapid Infuser and Pressure Bag infusions had no increase from baseline in plasma-free hemoglobin. Pressure Bag infusion was noted to confer an advantage in flow rates over Rapid Infuser. Intraosseous blood transfusion with pressure bags can safely bridge toward central access in the early phases of trauma resuscitation.

An Analysis of Adherence to Tactical Combat Casualty Care Guidelines for the Administration of Tranexamic Acid

Fisher AD, Carius BM, April MD, Naylor JF, Maddry JK, Schauer SG. An Analysis of Adherence to Tactical Combat Casualty Care Guidelines for the Administration of Tranexamic Acid. J Emerg Med. 2019 doi:https://doi.org/10.1016/j.jemermed.2019.08.027

Results. Within our dataset, 255 subjects received TXA. Four thousand seventy-one subjects had a tourniquet placed, of whom 135 (3.3%) received prehospital TXA; 1899 subjects had an amputation proximal to the digit with 106 (5.6%) receiving prehospital TXA; and 6660 subjects had a gunshot wound with 88 (1.3%) receiving prehospital TXA. Of 4246 subjects who received ≥10 units of blood products within the first 24 h, 177 (4.2%) received prehospital TXA.
Conclusions. We identified low TXA administration despite TCCC recommendations. Future studies should seek to both identify reasons for limited TXA administration and methods to increase future utilization.

Terrorist threat: Creating a nationwide damage control training program for non-trauma care providers

Swiech A, de Rocquigny G, Martinez T, et al. Terrorist threat: Creating a nationwide damage control training program for non-trauma care providers. Anaesthesia Critical Care & Pain Medicine. 2019 https://doi.org/10.1016/j.accpm.2019.09.011

Results. Existing DC training programs are heterogeneous, mainly theoretical and almost only for physicians. A program entitled Damage Control for Terrorist Attack Victims (DC-TAV) was then proposed. Identified training targets were care providers from prehospital and hospital staffs, with no experience in trauma care. The training objectives were the improvement of individual and collective skills in managing terrorist attacks casualties. The tools selected for training concerned e-learning on a dedicated digital teaching platform (including a core section of four modules with types and mechanisms of injury, basic DC techniques, triage, organisation of emergency medical response and two complementary modules for doctors with DC resuscitation including remote transfusion and DC surgery), hands-on workshops with procedural simulation and full-scale simulation exercises, technical (tourniquets, haemostatic gauzes, needle thoracostomy, chest tube drainage, management of airway, coniotomy) and non-technical (leadership, communication, coordination and triage, decision-making, appropriate use of resources) skills. Finally, an evaluation of the DC-TAV program was planned.
Conclusions. The DC-TAV program is an ambitious, civilian-military, nationwide and long-term program, based on a harmonised standard of care and including multidimensional training. Further studies are required to assess its efficacy.

Advances in the Management of Bleeding Trauma Patients

Kheirbek T, Monaghan SF, Benoit E, et al. Advances in the Management of Bleeding Trauma Patients. Rhode Island Medical Journal. 2019;102(8):30-33. (PDF)

Conclusion. Improved understanding of the pathophysiology of hemorrhage, coagulopathy, and resuscitation, along with technical advances and innovations, have improved outcomes of bleeding trauma patients. but there continues to be a need for early hemorrhage control. Involving bystanders appears to be a promising approach toward improving outcomes. Ongoing research and support by academic and government institutions is a crucial factor in combating mortality from traumatic hemorrhage – a serious public health problem.

The Challenge of Implementing the “Stop the Bleed” Campaign in Latin America

Orlas CP, Parra MW, Herrera-Escobar JP, et al. The Challenge of Implementing the “Stop the Bleed” Campaign in Latin America. J Surg Res. 2019 Oct 21. pii: S0022-4804(19)30687-0. doi: 10.1016/j.jss.2019.09.042. [Epub ahead of print]

Conclusion. The Stop the Bleed campaign can be effectively implemented in Latin America, and it can be taught by prequalified medical students without altering the learning objectives of the course.

Advanced Prehospital Trauma Resuscitation With a Physician and Certified Registered Nurse Anesthetist: The Shock Trauma “Go-Team”

Howie W, Scott-Herring M, Pollak AN, Galvagno SM. Advanced Prehospital Trauma Resuscitation With a Physician and Certified Registered Nurse Anesthetist: The Shock Trauma “Go-Team”. Air Medical Journal. 2019 DOI: https://doi.org/10.1016/j.amj.2019.09.004

Results. The majority of deployments were via helicopter (73%) and lasted 2 hours. The most common indications for deployment were motor vehicle entrapment (41%), trench collapse (14%), and building collapse (9%). Of the 22 patients treated by the Go-Team, 50% received at least 1 blood transfusion in the field, and 23% required an advanced airway. No field amputations were required.
Conclusion. The STC Go-Team is a unique multidisciplinary specialized component of a statewide emergency medical system.

Injury Patterns and Medical Evacuation of Patients in Chifeng Tornado in China, August 11, 2017

Zhao F, Hu C, Xu Z, Deng Q. Injury Patterns and Medical Evacuation of Patients in Chifeng Tornado in China, August 11, 2017. Disaster Medicine and Public Health Preparedness. 2019 [published online] DOI: https://doi.org/10.1017/dmp.2019.100

Results. A total of 148 injuries were diagnosed. Tornado-related injuries were mainly caused by collapsed houses (51.9%) and direct physical trauma caused by the tornado (38.5%). Most injuries occurred outdoors (63.5%). The head (20.3%) and thorax (14.8%) were most 2 frequent anatomical injury sites. Soft-tissue injuries (43.9%) and contusions and lacerations (37.3%) were the 2 most common injury types. On evaluating the Abbreviated Injury Scale scores, a score of 1 was the most common (66.2%), and a score of 6 was not recorded.
Conclusions. A trailing phenomenon in the distribution of time to admission among the victims of a particular tornado in China was observed. The delivery is timely compared with nondisaster situation. There was a statistically significant difference of injury causes between outdoor and indoor patients. Helmets should be used by potential tornado victims. Basement units capable of functioning as shelters should be built in villages.

Early Identification of Acute Lung Injury in a Porcine Model of Hemorrhagic Shock

Morris MC, Kim Y, Blakeman TC, et al. Early Identification of Acute Lung Injury in a Porcine Model of Hemorrhagic Shock. J Surg Research. 2019 doi: https://doi.org/10.1016/j.jss.2019.09.060

Results. Pigs that underwent hemorrhagic shock had higher heart rates, lower cardiac output, lower MAPs, and worse acidosis compared with sham at the early time points (P < 0.05 each). There were no significant differences in central venous pressure or pulmonary capillary wedge pressure between groups. Pulmonary neutrophil infiltration, as defined by neutrophil antibody staining on lung samples, was greater in the shock groups regardless of resuscitation fluid (P < 0.05 each). Bronchoalveolar lavage fluid neutrophil levels were not different between groups. There were no differences in levels of porcine surfactant protein D between groups at any time points, and the levels did not change over time in each respective group.
Conclusions. Our study demonstrates the reproducibility of a porcine model of hemorrhagic shock that is consistent with physiologic changes in humans in hemorrhagic shock. Pulmonary neutrophil infiltration may serve as an early marker for ALI; however, the practicality of this finding has yet to be determined.

A Decade of Damage Control Resuscitation: New Transfusion Practice, New Survivors, New Directions

Cole E, Weaver A, Gall L, et al. A Decade of Damage Control Resuscitation
New Transfusion Practice, New Survivors, New Directions. Ann Surg. 2019 [published ahead of print] doi: 10.1097/SLA.0000000000003657

Methods: A 10-year retrospective analysis of prospectively collected data of trauma patients who activated the Major Trauma Centre’s major hemorrhage protocol (MHP) and received at least 1 unit of red blood cell transfusions (RBC).
Results: A total of 1169 trauma patients activated the MHP and received at least 1 unit of RBC, with similar injury and admission physiology characteristics over the decade. Overall mortality declined from 45% in 2008 to 27% in 2017, whereas median RBC transfusion rates dropped from 12 to 4 units (massive transfusion rates from 68% to 24%). The proportion of deaths within 24 hours halved (33%–16%), principally with a fall in mortality between 3 and 24 hours (30%–6%). Survivors are now more likely to be discharged to their own home (57%–73%). Exsanguination is still the principal cause of early deaths, and the mortality associated with massive transfusion remains high (48%). Late deaths are now split between those due to traumatic brain injury (52%) and multiple organ dysfunction (45%).
Conclusions: There have been remarkable reductions in mortality after major trauma hemorrhage in recent years. Mortality rates continue to be high and there remain important opportunities for further improvements in these patients.

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