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Innovations in preoperative control of exsanguination in major trauma

02 June 2022
Volume 14 · Issue 6


Exsanguination places a considerable strain on trauma systems worldwide, and is estimated to be involved in 20–40% of trauma deaths. This article evaluates innovations in the preoperative care of the injured patient to minimise the impact of bleeding. These include reform of organisations and structure of trauma networks, adoption of objective prehospital triage tools and changes in ambulance crews' approach to on-scene interventions. Developments of methods to mechanically control these bleeds—simple tourniquets, topical haemostatics developed in military settings and endovascular interventions such as resuscitative endovascular balloon occlusion of the aorta—are also analysed. This article has examined advancements in damage control resuscitation, including a possible future shift towards whole-blood transfusion and interventional radiology for primary haemorrhage control. Finally, a potential further development—the uptake of hybrid resuscitation suites—is examined.

The reform of major trauma care in the NHS over the past two decades, with the establishment of regional major trauma networks, has been one of the most significant developments in the care of major trauma patients in the UK. A series of influential reports such as the National Confidential Enquiry into Patient Outcome and Death's (2007)Trauma—Who Cares? and the National Audit Office's (2010)Major Trauma Care in England highlighted systemic inadequacies in trauma care and helped guide these improvements.

The creation of a hierarchy of trauma services — major trauma centres, trauma units and local emergency hospitals—and careful development of prehospital triage tools to determine which of these services is required are two interventions that have been key to improving outcomes (McCullough et al, 2014).

This organisation of trauma systems has had a demonstrable benefit on morbidity and mortality for the most severely injured patients (MacKenzie et al, 2010), with Celso et al (2006) and Chesser et al (2019) showing 15% and 20% mortality reduction with their implementation respectively. Historically, this improvement was only seen a decade after their establishment (Nathens et al, 2004) but modern regional trauma networks have been shown to produce improvements within two years (Claridge et al, 2013).

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