Importance Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials. Objective To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. Design, Setting, and Participants Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013. Interventions Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled). Main Outcomes and Measures Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status. Results No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, −4.2% [95% CI, −9.6% to 1.1%]; P  = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, −3.7% [95% CI, −10.2% to 2.7%]; P  = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, −5.4% [95% CI, −10.4% to −0.5%]; P  = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P  = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P P Conclusions and Relevance Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups. Trial Registration clinicaltrials.gov Identifier:NCT01545232

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Transfusion of plasma, platelets, and red blood cells in a 1: 1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial

Background Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units. Methods We performed a retrospective chart review of 246 patients at a US Army combat support hospital, each of who received a massive transfusion (>/=10 units of RBCs in 24 hours). Three groups of patients were constructed according to the plasma to RBC ratio transfused during massive transfusion. Mortality rates and the cause of death were compared among groups. Results For the low ratio group the plasma to RBC median ratio was 1:8 (interquartile range, 0:12-1:5), for the medium ratio group, 1:2.5 (interquartile range, 1:3.0-1:2.3), and for the high ratio group, 1:1.4 (interquartile range, 1:1.7-1:1.2) (p Conclusions In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.

http://www.emergpa.net/wp/wp-content/uploads/2012/05/2007-Borgman-rato-pf-blood-products-transfused.pdf

The Ratio of Blood Products Transfused Affects Mortality in Patients Receiving Massive Transfusions at a Combat Support Hospital

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

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The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

European Resuscitation Council Guidelines for Resuscitation 2015

Purpose
To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS).

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Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome

: Rapid progress in trauma care occurs when the results of translational research are promptly integrated into clinical practice. Experience with a high volume of severely injured casualties expedites the process. Historically, these conditions have converged during times of conflict, improving the care of combat casualties and subsequently that of civilian trauma patients. In the most severely injured casualties, we know that when the lethal triad of hypothermia, acidosis, and coagulopathy are present, death is imminent. Current teaching is to avoid reaching these conditions by using damage control surgery. However, conventional resuscitation practice for damage control focuses on rapid reversal of acidosis and prevention of hypothermia, and surgical techniques focus on controlling hemorrhage and contamination. Direct treatment of coagulopathy has been relatively neglected, viewed as a byproduct of resuscitation, hemodilution, and hypothermia, and delayed by blood banking logistics. Damage control resuscitation addresses the entire lethal triad immediately upon admission to a combat hospital. By demonstrating that in the severely injured the coagulopathy of trauma is present at admission, recent studies have brought back to light the importance of treating this disorder at an earlier stage. Reports of lactated Ringer s solution and normal saline increasing reperfusion injury and leukocyte adhesion lead one to conclude that the standard crystalloid based resuscitation guidelines in pre hospital trauma life support (PHTLS) and advanced trauma life support (ATLS) may worsen the presenting acidosis and coagulopathy in severely injured trauma patients, and possibly increase ARDS, SIRS, and MOF. The safety of withholding PRBCs in hemodynamically stable patients has been demonstrated,18 and the risks associated with blood transfusion are well described.

Damage control resuscitation: Directly addressing the early coagulopathy of trauma

Contributors. Preface. Acknowledgements. 1 The Complex Abdomen (Tracy R. Bilski, Brian Rowlands and Adam Brooks). 2 Surgical Airways (Andrew Taylor). 3 The Chest (Ben Davies). 4 Lines (Adam Wolverson). 5 Pain (Trudy Towell and Jonathan Mole). 6 Feeding (Gabriel Rodrigues, Joy Field and Dileep Lobo). 7 Surgical Wounds (Alastair Simpson and Adam Brooks). 8 Surgical Drains (Sherif Awad, Alastair Simpson and Adam Brooks). 9 Hepatobiliary (Ian Beckingham, Sherif Awad, J. Edward Fitzgerald and Adam Brooks). 10 Stomas (Iain Anderson and Amanda Smith). 11 Urology (Gurminder Mann). 12 Central Nervous System (Jerard Ross, Dawn Williams and Neil Buxton). 13 Frames, Pins and Plaster (Ian Pallister). Index.

ABC of Tubes, Drains, Lines and Frames

In 1997, Professor J.M. Ryan and others produced the reference work Ballistic Trauma: Clinical Relevance in Peace and War (Arnold, 1997). Much of this is still valid, but a number of concepts in care of the ballistic casualty have changed. These include developing ideas on fluid resuscitation and refinement of field protocols based on operational experience. Authors, editors, and colleagues expressed the view that there was a need for a practical guide encompassing these developments, along the lines of Conflict and Catastrophe Medicine (Springer, 2002). The aim was to distill real-life practice and try to capture that which often is lost or diluted in traditional texts. With 9/11, the world changed. Since then, major conflicts have occurred in Afghanistan and Iraq, and operations are still ongoing. Many of the authors and editors deployed to these conflicts with nongovernmental organizations, Aid Agencies, and the military. Others are working with these injuries on a day-to-day basis at one of the USA’s busiest trauma centers. This has delayed the production of Ballistic Trauma: A Practical Guide, but means that people are writing with recent experience of managing ballistic injury. Colleagues returning from deployment have emphasized the need for clear guidance on managing ballistic injury, especially as more and more military reservists are being deployed and their day-to-day work may not include managing these types of injury. Authors have been given a relatively free hand in structuring their chapters so they would be unconstrained by the book’s style and be able to pass on their lessons unhindered. Finally, our request is that this book be a “living” document. Give us feedback. Record what treatment works and what treatment does not. Use this knowledge to improve the care of the ballistic casualty.

https://bilder.buecher.de/zusatz/22/22476/22476409_lese_1.pdf

Preface to the Second Edition: Why This Book, Why Now?

Medical facilities in all locations—urban, rural, or austere—need to prepare to receive casualties well before they arrive. In a civilian hospital, this is likely to involve activating the trauma team and notifying other key personnel. In a military field hospital, this preparation will include putting a system in place to remove safely the casualty’s weapons and ammunition (Figure 8-1). Casualties exposed to chemicals or other noxious agents will need decontamination before entering the hospital.

Peter F. Mahoney

Papers

Damage control resuscitation: Directly addressing the early coagulopathy of trauma

ABC of Tubes, Drains, Lines and Frames

Preface to the Second Edition: Why This Book, Why Now?

Resuscitation and Anesthesia for the Ballistic Casualty