Determining resuscitation outcomes in combat casualties: Design of the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock (Deployed HEROES) study

Recent advances on trauma management from the prehospital setting to in hospital care led to a better surviving severe trauma rate. Mortality from exsanguination remains the first preventable mortality. Damage-control resuscitation and surgery are evolving and thus some promising concepts are developing. Transfusion toolkit is brought on the prehospital scene while temporary bridge to hemostasis may be helpful. Panel transfusion products allow an individualized ratio assumed by fresh frozen or lyophilized plasma, fresh or cold-stored whole blood, fibrinogen, four-factor prothrombin complex concentrates. Growing interest is raising in whole blood transfusion, resuscitative endovascular balloon occlusion of the aorta use, hybrid emergency room, viscoelastic hemostatic assays to improve patient outcomes. Microcirculation, traumatic endotheliopathy, organ failures and secondary immunosuppression are point out since late deaths are increasing and may deserve specific treatment. As each trauma patient follows his own course over the following days after trauma, trauma management may be seen through successive, temporal, and individualized aims.

Section: In-hospital Resuscitationmentioning

confidence: 99%

Advances in trauma care to save lives from traumatic injury: A narrative review

Schmitt¹,

Gurney

Ariès

et al. 2023

“…[13][14][15][16][17] Despite the widespread use of UMT as an intervention for critical trauma patients, mortality rates remain as high as 40% to 80%. [13][14][15][16][17][18][19][20][21][22][23] Recognizing the limited availability of blood and the concerns surrounding ongoing transfusion in futile cases, studies have sought to investigate the concept of transfusion ceilings or cutoff point for high volume transfusion. 24,25 In 2022, Quintana et al 20 found a mortality plateau after 40.5 U, while Morris et al 22 in 2020 suggested futility after 80 U. Conversely, a military-focused study in 2023 by Gurney et al, 19 found a 24-hour mortality rate of only 20.7% for patients who received more than 100 U of blood.…”

mentioning

confidence: 99%

“…[13][14][15][16][17][18][19][20][21][22][23] Recognizing the limited availability of blood and the concerns surrounding ongoing transfusion in futile cases, studies have sought to investigate the concept of transfusion ceilings or cutoff point for high volume transfusion. 24,25 In 2022, Quintana et al 20 found a mortality plateau after 40.5 U, while Morris et al 22 in 2020 suggested futility after 80 U. Conversely, a military-focused study in 2023 by Gurney et al, 19 found a 24-hour mortality rate of only 20.7% for patients who received more than 100 U of blood. While this broad range of findings demonstrates the absence of a consensus threshold in our current literature, evidence does overarchingly support that increased blood product transfusion is not associated with increased survival and that the odds of mortality increase with increased products transfused.…”

mentioning

confidence: 99%

“…While this broad range of findings demonstrates the absence of a consensus threshold in our current literature, evidence does overarchingly support that increased blood product transfusion is not associated with increased survival and that the odds of mortality increase with increased products transfused. [14][15][16][18][19][20][21][22][23] Other studies have sought a more granular approach and to identify specific factors associated with improved outcomes. For example, a 2021 multicenter study by Matthay et al 15 found that a Glasgow Coma Scale (GCS) score of >3, age younger than 50 years, the absence of an emergency department (ED) thoracotomy, and normal platelet levels on admission were factors associated with improved survival.…”

mentioning

confidence: 99%

“…Ultramassive transfusion, specifically, is defined as transfusion of 20 U or more of red blood cell product within 24 hours of admission 13–17 . Despite the widespread use of UMT as an intervention for critical trauma patients, mortality rates remain as high as 40% to 80% 13–23 . Recognizing the limited availability of blood and the concerns surrounding ongoing transfusion in futile cases, studies have sought to investigate the concept of transfusion ceilings or cutoff point for high volume transfusion 24,25 …”

mentioning

confidence: 99%

See 2 more Smart Citations

TiME OUT: Time-specific machine-learning evaluation to optimize ultramassive transfusion

Meyer,

Nguyen,

ElHabr

et al. 2023

Background Ultra-massive transfusion (UMT) is a resource-demanding intervention for trauma patients in hemorrhagic shock and associated mortality rates remains high. Current research has been unable to identify a transfusion ceiling, or point where UMT transitions from life-saving to futility. Furthermore, little consideration has been given to how time-specific patient data points impact decisions with ongoing high-volume resuscitation. Therefore, this study sought to utilize time-specific machine learning (ML) modeling to predict mortality and identify parameters associated with survivability in trauma patients undergoing UMT. Methods A retrospective review was conducted at a Level I trauma (2018-2021) and included trauma patients meeting criteria for UMT, defined as >20 red blood cell products within 24 h of admission. Cross-sectional data was obtained from the blood bank and trauma registries and time-specific data was obtained from the electronic medical record. Time-specific decision-tree models (TS-DTM) predicating mortality were generated and evaluated using AUC. Results In the 180 patients included, mortality rate was 40.5% at 48-hours and 52.2% overall. The deceased received significantly more blood products with a median of 71.5 total units compared to 55.5 in the survivors (p < 0.001) and significantly greater rates of pRBC and FFP at each time interval. TS-DTM predicted mortality with an accuracy as high as 81%. In the early time intervals, hemodynamic stability, undergoing an emergency department thoracotomy and injury severity were most predictive of survival while in the later intervals, markers of adequate resuscitation such as arterial pH and lactate level became more prominent. Conclusions This study supports that the decision of “when to stop” in UMT resuscitation is not based exclusively on the number of units transfused, but rather the complex integration of patient and time-specific data. ML is an effective tool to investigate this concept and further research is needed to refine and validate these TS-DTM. Level of Evidence IV, Retrospective cohort review

The thin red line: Blood planning factors and the enduring need for a robust military blood system to support combat operations

Gurney,

Cap,

Holcomb

et al. 2024

Battlefield lessons learned are forgotten; the current name for this is the Walker Dip. Blood transfusion and the need for a Department of Defense Blood Program are lessons that have cycled through being learned during wartime, forgotten, and then relearned during the next war. The military will always need a blood program to support combat and contingency operations. Also, blood supply to the battlefield has planning factors that have been consistent over a century. In 2024, it is imperative that we codify these lessons learned. The linchpins of modern combat casualty care are optimal prehospital care, early whole blood transfusion, and forward surgical care. This current opinion comprised of authors from all three military Services, the Joint Trauma System, the Armed Services Blood Program, blood SMEs and the CCC Research Program discuss two vital necessities for a successful military trauma system: (1) the need for an Armed Services Blood Program and (2) Planning factors for current and future deployed military ere is no effective care for wounded soldiers, and by extension there is no effective military medicine.