After 800 Mtp Events, Mortality Due to Hemorrhagic Shock Remains High and Unchanged Despite Several In-Hospital Hemorrhage Control Advancements

Abstract

Background: Numerous advancements in hemorrhage control and volume replacement that comprise damage control resuscitation (DCR) have been implemented in the last decade to reduce deaths from bleeding. We sought to determine the impact of DCR interventions on mortality over 12 years in a massive transfusion protocol (MTP) population. We hypothesized that mortality would be decreased in later years, which would have used more DCR interventions. Study Design: This was a retrospective review of all MTP patients treated at a large regional Level I trauma center from 2008 to 2019. Interventions by year of implementation examined included MTP 1:1 ratio ( 2009), liquid plasma (2010), tranexamic acid (2012), prehospital tourniquets (2013), REBOA/TEG (2017), satellite blood station (2018), and whole blood transfusion (2019). Relative risk and odds of mortality for DCR interventions were examined. Results: There were 824 MTP patients included. The cohort was primarily male (80.6%) injured by penetrating mechanism (68.1%) with median (interquartile range) age 31 years (23-44) and New Injury Severity Score 25 (16-34). Overall mortality was unchanged [(38.3%-56.6%); P ¼ 0.26]. Tourniquets (P ¼ 0.02) and whole blood (WB) (P ¼ 0.03) were associated with lower unadjusted mortality; only tourniquets remained significant after adjustment (OR: 0.39; 95% CI: 0.17-0.89; P ¼ 0.03). Conclusions: Despite lower mortality with use of tourniquets and WB, mortality rates due to hemorrhage have not improved at our high MTP volume institution, suggesting implementation of new in-hospital strategies is insufficient to reduce mortality. Future efforts should be directed toward moving hemorrhage control and effective resuscitation interventions to the injury scene.

Impact of time to surgery on mortality in hypotensive patients with noncompressible torso hemorrhage: An AAST multicenter, prospective study

“…18 These interventions are not current practice in the prehospital phase of civilian trauma care in the United States; however, as military successes in trauma care often cross into civilian care, use of whole blood or modified (leukoreduced) whole blood is experiencing renewed interest. [19][20][21][22][23] Prehospital administration of plasma, packed red blood cells, and whole blood have each been examined to varying degrees in the civilian sector and have been associated with survival benefit. [23][24][25] However, implementation in many areas has been slow, and the practices have yet to become widely adopted.…”

“…To realize this potential benefit and to reduce what have become stagnant mortality rates in this patient population despite numerous in-hospital advancements, evidence-based improvements in prehospital care driven by the military must find their way into the civilian arena. 12,21 Lastly, trauma care has long emphasized the ABCssequential priorities of Airway, Breathing, and Circulation-as standard of care in treatment of the critically injured patient. However, the order of this sequence has recently been called into question, particularly for patients who are in hypovolemic shock with ventilation perfusion mismatch.…”

“…However, both median (IQR) ED time (27 minutes [16-63 minutes]) and median (IQR) time from ED to OR start (48 minutes [30-85 minutes]) were significantly shorter in the nonsurviving group ( p ≤ 0.04 for both). There was no difference in median (IQR) OR preparation time between groups (15 [10][11][12][13][14][15][16][17][18][19][20][21][22] survivors vs. 13 [8][9][10][11][12][13][14][15][16][17][18][19] nonsurvivors; p = 0.09). When analyzing the continuum of care from time of injury to OR start (84 [58-117 minutes]), the deceased group had significantly shorter time ( p = 0.03).…”

Dynamic use of fibrinogen under viscoelastic assessment results in reduced need for plasma and diminished overall transfusion requirements in severe trauma

“…Regarding this hypothesis, it is interesting to highlight the results from the Duchesne group's review. 57 In their high MTP volume institution, they analyzed changes in the mortality rate related to the implementation of different damage control resuscitation interventions (including MTP 1:1 ratio, TXA, TEG or whole blood). They concluded that mortality rates due to hemorrhage has not improve despite the implementation of these strategies, suggesting implementation of new in-hospital strategies is insufficient to reduce mortality.…”

“…Hemorrhagic shock following injury has been shown to induce coagulopathy within minutes, which may exacerbate bleeding. This coagulopathy, referred to as trauma-induced coagulopathy (TIC) is associated with a fourfold increase in mortality 3–6 . For these reasons, several strategies have been proposed to rapidly improve hemostasis and to ameliorate TIC in what has been called hemostatic resuscitation (HR).…”