Purpose: Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine whether augmenting MHPs with Viscoelastic Haemostatic Assays (VHA) would improve outcomes compared to Conventional Coagulation Tests (CCTs). Methods: This was a multi-centre, randomized controlled trial comparing outcomes in trauma patients who received empiric MHPs, augmented by either VHA or CCT-guided interventions. Primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of massive transfusion (10 or more red cell transfusions). Secondary outcomes included 28-day mortality. Pre-specified subgroups included patients with severe traumatic brain injury (TBI). Results: Of 396 patients in the intention to treat analysis, 201 were allocated to VHA and 195 to CCT-guided therapy. At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%, OR 1.15, 95% CI 0.76-1.73). 28-day mortality was not different overall (VHA: 25%, CCT: 28%, OR 0.84, 95% CI 0.54-1.31), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups, there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm (OR 2.12, 95% CI 0.84-5.34). Conclusion: There was no difference in overall outcomes between VHA-and CCT-augmented-major haemorrhage protocols.

Transfusion of red cell concentrates (RCCs) is associated with increased risk of adverse outcomes that may be affected by different blood manufacturing methods and the presence of extracellular vesicles (EVs). We investigated the effect of different manufacturing methods on hemolysis, residual cells, cell-derived EVs, and immunomodulatory effects on monocyte activity. Thirty-two RCC units produced using whole blood filtration (WBF), red cell filtration (RCF), apheresis-derived (AD), and whole blood-derived (WBD) methods were examined (n = 8 per method). Residual platelet and white blood cells (WBCs) and the concentration, cell of origin, and characterization of EVs in RCC supernatants were assessed in fresh and stored supernatants. Immunomodulatory activity of RCC supernatants was assessed by quantifying monocyte cytokine production capacity in an in vitro transfusion model. RCF units yielded the lowest number of platelet and WBC-derived EVs, whereas the highest number of platelet EVs was in AD (day 5) and in WBD (day 42). The number of small EVs (<200 nm) was greater than large EVs (≥200 nm) in all tested supernatants, and the highest level of small EVs were in AD units. Immunomodulatory activity was mixed, with evidence of both inflammatory and immunosuppressive effects. Monocytes produced more inflammatory interleukin-8 after exposure to fresh WBF or expired WBD supernatants. Exposure to supernatants from AD and WBD RCC suppressed monocyte lipopolysaccharide-induced cytokine production. Manufacturing methods significantly affect RCC unit EV characteristics and are associated with an immunomodulatory effect of RCC supernatants, which may affect the quality and safety of RCCs.

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Total-body CT (TBCT) scanning in trauma patients is being increasingly used in trauma assessment. One of the major disadvantages of CT scanning is the amount of radiation exposure involved. The aim of this study was to assess the number of radiological investigations and their associated radiation exposure in multitrauma patients before and after the introduction of a total-body CT protocol as a primary diagnostic tool. The Trauma Registry was used to identify trauma patients admitted to our Level 1 trauma centre in 2008 (pre-TBCT protocol) and 2010 (post-TBCT protocol). Consecutive patients with an Injury Severity Score of ≥16 were included. Patients aged 16 or under, referrals from other hospitals and patients with specific low-energy injury mechanisms were excluded. Subsequent effective doses were estimated from literature and from dose calculations. Three hundred one patients were included, 150 patients pre- and 151 post-introduction of the TBCT protocol. Demographics were comparable. In 2008, 20 % of severely injured patients underwent total-body CT scan, compared with 46 % of the patients in 2010. Trauma room radiation doses for conventional radiographs were significantly higher in 2008, while doses for CT scans were significantly lower. The total effective dose of trauma room radiological investigations was 16 milliSieverts (mSv) in 2008 vs. 24 mSv in 2010 (P = 0.223). The overall effective dose during the total hospital admission was not significantly different between 2008 and 2010 (20 vs. 24 mSv, P = 0.509).In conlusion, after the introduction of a dedicated TBCT protocol, the TBCT rate was more than doubled. Although this increased the CT-induced trauma room radiation dose, the overall radiation dose throughout hospital admission was comparable between patients in 2008 and 2010.

Essentials The response of thromboelastometry (ROTEM) parameters to therapy is unknown.We prospectively recruited hemorrhaging trauma patients in six level‐1 trauma centres in Europe.Blood products and pro‐coagulants prevent further derangement of ROTEM results.ROTEM algorithms can be used to treat and monitor trauma induced coagulopathy. SummaryBackgroundRotational thromboelastometry (ROTEM) can detect trauma‐induced coagulopathy (TIC) and is used in transfusion algorithms. The response of ROTEM to transfusion therapy is unknown.ObjectivesTo determine the response of ROTEM profiles to therapy in bleeding trauma patients.Patients/MethodsA prospective multicenter study in bleeding trauma patients (receiving ≥ 4 red blood cell [RBC] units) was performed. Blood was drawn in the emergency department, after administration of 4, 8 and 12 RBC units and 24 h post‐injury. The response of ROTEM to plasma, platelets (PLTs), tranexamic acid (TXA) and fibrinogen products was evaluated in the whole cohort as well as in the subgroup of patients with ROTEM values indicative of TIC.ResultsThree hundred and nine bleeding and shocked patients were included. A mean dose of 3.8 g of fibrinogen increased FIBTEM CA5 by 5.2 mm (IQR: 4.1–6.3 mm). TXA administration decreased lysis by 5.4% (4.3–6.5%). PLT transfusion prevented further derangement of parameters of clot formation. The effect of PLTs on EXTEM ca5 values was more pronounced in patients with a ROTEM value indicative of TIC than in the whole cohort. Plasma transfusion decreased EXTEM clotting time by 3.1 s (− 10 s to 3.9 s) in the whole cohort and by 10.6 s (− 45 s to 24 s) in the subgroup of patients with a ROTEM value indicative of TIC.ConclusionThe effects of therapy on ROTEM values were small, but prevented further derangement of test results. In patients with ROTEM values indicative of TIC, the efficacy of PLTs and plasma in correcting deranged ROTEM parameters is possibly more robust.