References

Barnes A. Transfusion of universal donor and uncrossmatched blood. Bibl Haematol. 1980; (46)132-142 https://doi.org/10.1159/000430554

Bekdache O, Paradis T, Shen YBH Resuscitative endovascular balloon occlusion of the aorta (REBOA): indications: advantages and challenges of implementation in traumatic non-compressible torso hemorrhage. Trauma Surg Acute Care Open. 2019; 4:(1)1-7 https://doi.org/10.1136/tsaco-2018-000262

Bolliger D, Seeberger MD, Tanaka KA. Principles and practice of thromboelastography in clinical coagulation management and transfusion practice. Transfus Med Rev. 2012; 26:(1)1-13 https://doi.org/10.1016/j.tmrv.2011.07.005

Border JR, Lewis FR, Aprahamian C, Haller JA, Jacobs LM, Luterman A. Panel: prehospital trauma care—stabilize or scoop and run. J Trauma. 1983; 23:(8)708-711 https://doi.org/10.1097/00005373-198308000-00005

Brenner M, Inaba K, Aiolfi A Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy in select patients with hemorrhagic shock: early results from the American Association for the Surgery of Trauma's Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery Registry. J Am Coll Surg. 2018; 226:(5)730-740 https://doi.org/10.1016/j.jamcollsurg.2018.01.044

Bukur M, Teurel C, Catino J, Kurek S. The price of always saying yes: a cost analysis of secondary overtriage to an urban level I trauma center. Am Surg. 2018; 84:(8)1368-1375 https://doi.org/10.1177/000313481808400854

Cap AP. Plasmin: a driver of hemovascular dysfunction. Blood. 2016; 128:(20)2375-2376 https://doi.org/10.1182/blood-2016-09-735720

Cap AP. CRASH-3: a win for patients with traumatic brain injury. Lancet. 2019; 394:(10210)1687-1688 https://doi.org/10.1016/S0140-6736(19)32312-8

Cassignol A, Marmin J, Cotte J Correlation between field triage criteria and the injury severity score of trauma patients in a French inclusive regional trauma system. Scand J Trauma Resusc Emerg Med. 2019; 27:(1) https://doi.org/10.1186/s13049-019-0652-0

Celso B, Tepas J, Langland-Orban B A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma. 2006; 60:(2)371-378 https://doi.org/10.1097/01.ta.0000197916.99629.eb

Chesser TJS, Moran C, Willett K Development of trauma systems in Europe—reports from England, Germany, the Netherlands, and Spain. OTA International. 2019; 2:(S1) https://doi.org/10.1097/OI9.0000000000000019

Claridge JA, Allen D, Patterson B Regional collaboration across hospital systems to develop and implement trauma protocols saves lives within 2 years. Surgery. 2013; 154:(4)875-882 https://doi.org/10.1016/j.surg.2013.07.013

Curry NS, Davenport R. Transfusion strategies for major haemorrhage in trauma. Br J Haematol. 2019; 184:(4)508-523 https://doi.org/10.1111/bjh.15737

D'Amours SK, Rastogi P, Ball CG. Utility of simultaneous interventional radiology and operative surgery in a dedicated suite for seriously injured patients. Curr Opin Crit Care. 2013; 19:(6)587-593 https://doi.org/10.1097/MCC.0000000000000031

David JS, Bouzat P, Raux M. Evolution and organisation of trauma systems. Anaesth Crit Care Pain Med. 2019; 38:(2)161-167 https://doi.org/10.1016/j.accpm.2018.01.006

Delgado MK, Yokell MA, Staudenmayer KL, Spain DA, Hernandez-Boussard T, Wang NE. Factors associated with the disposition of severely injured patients initially seen at non–trauma center emergency departments: disparities by insurance status. JAMA Surg. 2014; 149:(5)422-430 https://doi.org/10.1001/jamasurg.2013.4398

Eckstein M, Chan L, Schneir A, Palmer R. Effect of prehospital advanced life support on outcomes of major trauma patients. J Trauma. 2000; 48:(4)643-648 https://doi.org/10.1097/00005373-200004000-00010

Farah J, Goebel M, Pierce J, Donofrio JJ. Epidemiology of prehospital care at the San Diego (USA)–Tijuana (Mexico) international border crossing. Prehosp Emerg Care. 2020; 24:(3)335-340 https://doi.org/10.1080/10903127.2019.1640325

Fisher AD, Miles EA, Cap AP, Strandenes G, Kane SF. Tactical damage control resuscitation. Mil Med. 2015; 180:(8)869-875 https://doi.org/10.7205/MILMED-D-14-00721

Frykberg ER. Medical management of disasters and mass casualties from terrorist bombings: how can we cope?. J Trauma. 2002; 53:(2)201-212 https://doi.org/10.1097/00005373-200208000-00001

Fuller G, Lawrence T, Woodford M, Lecky F. The accuracy of alternative triage rules for identification of significant traumatic brain injury: a diagnostic cohort study. Emerg Med J. 2014; 31:(11)914-919 https://doi.org/10.1136/emermed-2013-202575

Goodwin T, Moore KN, Pasley JD, Troncoso R, Levy MJ, Goolsby C. From the battlefield to main street: tourniquet acceptance, use, and translation from the military to civilian settings. J Trauma Acute Care Surg. 2019; 87:(1S)S35-S39 https://doi.org/10.1097/TA.0000000000002198

Gould JE, Vedantham S. The role of interventional radiology in trauma. Semin Intervent Radiol. 2006; 23:(3)270-278 https://doi.org/10.1055/s-2006-948766

Gulland A. ‘It wasn't a medical miracle—we made our own luck’: lessons from London and Manchester terror attacks. BMJ. 2017; 358 https://doi.org/10.1136/bmj.j4309

Güven HE. Topical hemostatics for bleeding control in pre-hospital setting: then and now. Ulus Travma Acil Cerrahi Derg. 2017; 23:(5)357-361 https://doi.org/10.5505/tjtes.2017.47279

Holcomb JB. Damage control resuscitation. J Trauma. 2007; 62:S36-37 https://doi.org/10.1097/TA.0b013e3180654134

Holcomb JB, del Junco DJ, Fox EE The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013; 148:(2)127-136 https://doi.org/10.1001/2013.jamasurg.387

Holcomb JB, Tilley BC, Baraniuk S 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. JAMA. 2015; 313:(5)471-482 https://doi.org/10.1001/jama.2015.12

Howell GM, Peitzman AB, Nirula R Delay to therapeutic interventional radiology postinjury: time is of the essence. J Trauma. 2010; 68:(6)1296-1300 https://doi.org/10.1097/TA.0b013e3181d990b5

Karon BS. Why is everyone so excited about the thromboelastography (TEG)?. Clinica Chimica Acta. 2014; 436:143-148 https://doi.org/10.1016/j.cca.2014.05.013

Keneally RJ, Parsons AM, Willett PB. Warm fresh whole blood and thoracic trauma in Iraq and Afghanistan. J Emerg Trauma Shock. 2015; 8:(1)21-25 https://doi.org/10.4103/0974-2700.150392

Kinoshita T, Yamakawa K, Matsuda H The survival benefit of a novel trauma workflow that includes immediate whole-body computed tomography, surgery, and interventional radiology, all in one trauma resuscitation room: a retrospective historical control study. Ann Surg. 2019; 269:(2)370-376 https://doi.org/10.1097/SLA.0000000000002527

Lendrum R, Perkins Z, Chana M Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) for exsanguinating pelvic haemorrhage. Resuscitation. 2019; 135:6-13 https://doi.org/10.1016/j.resuscitation.2018.12.018

MacKenzie EJ, Rivara FP, Jurkovich GJ A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006; 354:(4)366-378 https://doi.org/10.1056/NEJMsa052049

MacKenzie EJ, Weir S, Rivara FP The value of trauma center care. J Trauma. 2010; 69:(1)1-10 https://doi.org/10.1097/TA.0b013e3181e03a21

Martin M, Izenberg S, Cole F, Bergstrom S, Long W. A decade of experience with a selective policy for direct to operating room trauma resuscitations. Am J Surg. 2012; 204:(2)187-192 https://doi.org/10.1016/j.amjsurg.2012.06.001

Matsumoto J, Lohman BD, Morimoto K, Ichinose Y, Hattori T, Taira Y. Damage control interventional radiology (DCIR) in prompt and rapid endovascular strategies in trauma occasions (PRESTO): a new paradigm. Diagn Interv Imaging. 2015; 96:(7–8)687-691 https://doi.org/10.1016/j.diii.2015.06.001

McCullough AL, Haycock JC, Forward DP, Moran CG. Major trauma networks in England. Br J Anaesth. 2014; 113:(2)202-206 https://doi.org/10.1093/bja/aeu204

Meizoso JP, Valle EJ, Allen CJ Decreased mortality after prehospital interventions in severely injured trauma patients. J Trauma Acute Care Surg. 2015; 79:(2)227-231 https://doi.org/10.1097/TA.0000000000000748

Nadler R, Tsur AM, Yazer MH Early experience with transfusing low titer group O whole blood in the pre-hospital setting in Israel. Transfusion. 2020; 60:S10-S16 https://doi.org/10.1111/trf.15602

Nathens AB, Jurkovich GJ, MacKenzie EJ, Rivara FP. A resource-based assessment of trauma care in the United States. J Trauma. 2004; 56:(1)173-178 https://doi.org/10.1097/01.TA.0000056159.65396.7C

National Audit Office. Major trauma care in England. 2010. https://www.nao.org.uk/report/major-trauma-care-in-england/ (accessed 13 May 2022)

National Confidential Enquiry into Patient Outcome and Death. Trauma: who cares?. 2007. https://www.ncepod.org.uk/2007report2/Downloads/SIP_summary.pdf (accessed 12 May 2022)

Newgard CD, Fu R, Zive D Prospective validation of the national field triage guidelines for identifying seriously injured persons. J Am Coll Surg. 2016; 222:(2)146-158.e2 https://doi.org/10.1016/j.jamcollsurg.2015.10.016

Peters J, van Wageningen B, Hendriks I First-pass intubation success rate during rapid sequence induction of prehospital anaesthesia by physicians versus paramedics. Eur J Emerg Med. 2015; 22:(6)391-394 https://doi.org/10.1097/MEJ.0000000000000161

Pfeifer R, Halvachizadeh S, Schick S Are pre-hospital trauma deaths preventable? A systematic literature review. World J Surg. 2019; 43:(10)2438-2446 https://doi.org/10.1007/s00268-019-05056-1

Pivalizza EG, Stephens CT, Sridhar S Whole blood for resuscitation in adult civilian trauma in 2017: a narrative review. Anesth Analg. 2018; 127:(1)157-162 https://doi.org/10.1213/ANE.0000000000003427

Radwan MM, Abu-Zidan FM. Focussed assessment sonograph trauma (FAST) and CT scan in blunt abdominal trauma: surgeon's perspective. Afr Health Sci. 2006; 6:(3)187-190 https://doi.org/10.5555/afhs.2006.6.3.187

Ran Y, Hadad E, Daher S QuikClot Combat Gauze use for hemorrhage control in military trauma: January 2009 Israel Defense Force experience in the Gaza Strip—a preliminary report of 14 cases. Prehosp Disaster Med. 2010; 25:(6)584-588 https://doi.org/10.1017/S1049023X00008797

Roberts I, Shakur H, Coats T The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013; 17:(10)1-79 https://doi.org/10.3310/hta17100

Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am. 1997; 77:(4)761-777 https://doi.org/10.1016/S0039-6109(05)70582-X

Russo RM, Williams TK, Grayson JK Extending the golden hour: partial resuscitative endovascular balloon occlusion of the aorta in a highly lethal swine liver injury model. J Trauma Acute Care Surg. 2016; 80:(3)372-378 https://doi.org/10.1097/TA.0000000000000940

Saied A, Ayatollahi Mousavi A, Arabnejad F, Ahmadzadeh Heshmati A. Tourniquet in surgery of the limbs: a review of history, types and complications. Iran Red Crescent Med J. 2015; 17:(2) https://doi.org/10.5812/ircmj.9588

Shanahan TAG, Fuller GW, Sheldon T, Turton E, Quilty FMA, Marincowitz C. External validation of the Dutch prediction model for prehospital triage of trauma patients in South West region of England, United Kingdom. Injury. 2021; 52:(5)1108-1116 https://doi.org/10.1016/j.injury.2021.01.039

Sigal A, Martin A, Ong A. Availability and use of hemostatic agents in prehospital trauma patients in Pennsylvania translation from the military to the civilian setting. Open Access Emerg Med. 2017; 9:47-52 https://doi.org/10.2147/OAEM.S134657

Smith RM, Conn AK. Prehospital care—scoop and run or stay and play?. Injury. 2009; 40:S23-S236 https://doi.org/10.1016/j.injury.2009.10.033

Tactical Combat Casualty Care. Basic management plan for care under fire. 2020. https://tinyurl.com/msj53bv9 (accessed 12 May 2022)

Van PY, Holcomb JB, Schreiber MA. Novel concepts for damage control resuscitation in trauma. Curr Opin Crit Care. 2017; 23:(6)498-502 https://doi.org/10.1097/MCC.0000000000000455

van Rein EAJ, van der Sluijs R, Raaijmaakers AMR, Leenen LPH, van Heijl M. Compliance to prehospital trauma triage protocols worldwide: a systematic review. Injury. 2018; 49:(8)1373-1380 https://doi.org/10.1016/j.injury.2018.07.001

Voskens FJ, van Rein EAJ, van der Sluijs R Accuracy of prehospital triage in selecting severely injured trauma patients. JAMA Surg. 2018; 153:(4)322-327 https://doi.org/10.1001/jamasurg.2017.4472

Wilson SL, Gangathimmaiah V. Does prehospital management by doctors affect outcome in major trauma? A systematic review. J Trauma Acute Care Surg. 2017; 83:(5)965-974 https://doi.org/10.1097/TA.0000000000001559

Winstanley M, Smith JE, Wright C. Catastrophic haemorrhage in military major trauma patients: a retrospective database analysis of haemostatic agents used on the battlefield. J R Army Med Corps. 2019; 165:(6)405-409 https://doi.org/10.1136/jramc-2018-001031

Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017; 389:(10084)2105-2116 https://doi.org/10.1016/S0140-6736(17)30638-4

Yazer MH, Spinella PC. Review of low titre group O whole blood use for massively bleeding patients around the world in 2019. ISBT Science Series. 2019; 14:(3)276-281 https://doi.org/10.1111/voxs.12495

Yazer MH, Spinella PC. An international survey on the use of low titer group O whole blood for the resuscitation of civilian trauma patients in 2020. Transfusion. 2020; 60:(S3)S176-S179 https://doi.org/10.1111/trf.15601

Yousefifard M, Askarian-Amiri S, Madani Neishaboori A, Sadeghi M, Saberian P, Baratloo A. Pre-hospital pain management; a systematic review of proposed guidelines. Arch Acad Emerg Med. 2019; 7:(1) https://doi.org/10.22037/aaem.v7i1.480

Zielinski MD, Jenkins DH, Hughes JD, Badjie KS, Stubbs JR. Back to the future: the renaissance of whole-blood transfusions for massively hemorrhaging patients. Surgery. 2014; 155:(5)883-886 https://doi.org/10.1016/j.surg.2014.01.017

Innovations in preoperative control of exsanguination in major trauma

02 June 2022
Volume 14 · Issue 6

Abstract

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).

However, this development has been accompanied by a loss of resuscitative skills in non-major trauma centres. This is problematic if the capacity of trauma centres is overwhelmed in the event of a mass casualty incident (David et al, 2019).

The development of specific triage tools that partnered the inception of trauma networks has been key to improving outcomes. This involves striking a difficult balance, with the rates of under-triage (a patient with major trauma (Injury Severity Score (ISS) >15) being sent to a non-trauma centre) and over-triage (a patient without major trauma (ISS <16) being sent to a major trauma centre) both ideally being minimised. Although ISS is calculated retrospectively, it remains the gold standard for defining major trauma (Cassignol et al, 2019). There is no defined acceptable rate of these triage errors in the UK but trauma systems in the US typically allow 5% under-triage and 50% over-triage (Voskens et al, 2018).

Rapid on-scene prediction tools have shown potential to reduce under-triage rates, particularly among the elderly population with seemingly innocuous mechanisms of injury (Delgado et al, 2014). Reducing this is clearly beneficial for patients experiencing major trauma; triage of moderate and severe head injuries to level I US trauma centres rather than non-trauma centres has been shown to reduce mortality (MacKenzie et al, 2006).

However, this safety improvement comes at the expense of increased over-triage (Shanahan et al, 2021), which leads to significant costs (Bukur et al, 2018) and resources being stretched in major trauma centres. Research following the 2001 terrorist attack on the World Trade Center showed a direct correlation between over-triage and mortality rates in severely injured patients (Frykberg, 2002).

Although paramedics are expected to follow triage protocols uniformly, adherence varies across regions enormously and a prospective cohort study in the US showed that the subjective judgement of the emergency provider was the most commonly adopted triage tool (Newgard et al, 2016). It has been suggested this may be because triage tools have poor sensitivity, particularly for elderly patients (van Rein et al, 2018).

Efforts to improve this triage process are continuous, with some emergency services attempting to refine it by actively anticipating changes in trauma demographics (Farah et al, 2020). Nonetheless, the importance of these triage systems and their value to the coordination of trauma services is widely agreed upon (Fuller et al, 2014).

Exsanguination places an enormous burden on trauma systems worldwide. Epidemiological studies typically document it is involved in 20–40% of trauma deaths, the majority of which occur within a few hours of injury (Holcomb et al, 2013; 2015). The immediate control of the exsanguinating trauma patient is a source of much ongoing research and deliberation (Curry and Davenport, 2019) and covers an enormous scope of clinical practice.

Efforts to reduce this burden on healthcare systems began with structural changes, as described above, and preventive strategies such as the mandatory use of seat belts and improved car and airbag construction. The other elements of this, which will be explored in this article, are prehospital interventions, damage control resuscitation and interventional radiology (IR).

Prehospital care

The commonest and most immediate setting of trauma-related mortality is the scene of the incident. Pfeifer et al's (2019) systematic review of more than 7000 trauma deaths found up to 47.6% of these occurred in the prehospital setting. It can therefore be argued that prehospital care is the most important facet of trauma treatment.

Historically, two distinct philosophies existed: either an intervention and procedure-scarce strategy, which minimises the time spent at a scene in an attempt to initiate definitive resuscitation and operative/radiological management in a major trauma centre—known as ‘scoop and run’; or an intervention-heavy approach, where highly trained paramedics, anaesthetists or emergency physicians are able to provide high-level care including intubation and induction of general anaesthesia—known as ‘stay and play’ (Smith and Conn, 2009).

These two methods were debated by the American Association for the Surgery of Trauma in 1982 (Border et al, 1983) and have been compared ever since. The majority of evidence has supported a scoop-and-run policy in major trauma; however, a third category of ‘play without extending play’ has been suggested. This technique, where skilled emergency providers perform only life-saving prehospital interventions, was found not to increase time at the scene nor total prehospital time and decreased mortality rates in the most severely injured patients by 50% in a retrospective analysis of prehospital interventions of 3733 consecutive trauma patients attending a US level I trauma centre (Meizoso et al, 2015).

Although, historically, the presence of doctors in the prehospital setting was shown to improve intubation rates and patient satisfaction for pain control (Eckstein et al, 2000), contemporaneous literature has demonstrated pain relief administration by paramedics is effective (Yousefifard et al, 2019) and there is no good-quality evidence showing higher successful intubation rates in comparisons between paramedics and non-anaesthetic doctors (Peters et al, 2015). There is also insufficient evidence to show that improved prehospital pain relief and intubation rates improve mortality, particularly in the setting of major haemorrhage (Wilson and Gangathimmaiah, 2017).

One of the paradoxes of the two approaches to prehospital trauma care is the distribution of expertise in urban versus rural settings. The scoop-and-run strategy is associated with improved outcomes for trauma patients in urban environments where transfer times are short; this is the setting where most experience and competency in advanced skills are concentrated but also where they are least likely to be used. Another factor to be considered is that, because of the higher populations in urban areas, paramedics will generally have fewer exposures to critically unwell patients requiring these advanced skills. Even when exposed, paramedics in urban areas are likely to receive less educational benefit than from an equivalent encounter in a rural setting because treatment is likely to be led by other assets deployed to the scene (Mulholland, 2010). This is also problematic for maintaining skills as nobody is able to sufficiently preserve skills if they practise them only a few times a year (Smith and Conn, 2009).

As stated above, significant early haemorrhage accounts for a substantial proportion of trauma morbidity and mortality. Consequently, innovations in methods to mechanically control haemorrhage have advanced rapidly. This is particularly relevant to military settings as battlefield analyses have associated haemorrhage with 90% of survivable injuries (Winstanley et al, 2019).

Tourniquets for extremity haemorrhage were first documented in the Roman era and their use is common today, albeit with practitioners having a greater appreciation of the complications of prolonged tourniquet times than their Roman counterparts (Saied et al, 2015). War has been the primary driver for their advancement, with the training of all military personnel in tourniquet application in recent conflicts in Afghanistan and Iraq contributing to unprecedented survival rates for battlefield injury (Goodwin et al, 2019).

In patients not suitable for tourniquet application—mainly those with junctional haemorrhage, such as in the neck, axilla and inguinal regions, which accounted for 19.2% of injuries causing death in US soldiers in Iraq and Afghanistan between 2001 and 2011—topical haemostatics are invaluable (Güven, 2017). A host of different compounds are available for this, with the most recent Tactical Combat Casualty Care (2020) guidelines stipulating the use of a ‘combat gauze’ dressing (surgical gauze with kaolin) (Ran et al, 2010) in association with a kaolin-based topical haemostat (which augments the activation of factors XI and XII) and a chitosan-based agent used as second line (this positively charged surface recruits erythrocytes, physically closing the haemorrhage site and causing vasoconstriction) (Güven, 2017; Tactical Combat Casualty Care, 2020).

Civilian mass casualty events, such as terrorist bombings in which injury patterns mirror those seen in military settings, have created a requirement to transfer this haemorrhage control practice to emergency providers (Gulland, 2017). It has taken time to translate this to the civilian setting; although the use of topical haemostatics among emergency crews is increasing, retrospective surveys of US paramedics showed fewer than half had used a topical haemostatic in the previous year. The causes for this appear to be a lack of clear indications for their use, low availability and a lack of experience and comfort with the products (Sigal et al, 2017).

Another direction for the prehospital control of major haemorrhage has been endovascular interventions. These have been developed for non-compressible bleeds that are not amenable to tourniquets or topical haemostats. One such example is resuscitative endovascular balloon occlusion of the aorta (REBOA). This involves cannulation of the femoral artery and inflation of an endovascular balloon at various points of the aorta (zone 1=between the left subclavian and coeliac trunk; zone 2=between the coeliac trunk and the origin of the renal arteries; zone 3=between the origin of the renal arteries and the bifurcation of aorta) to reduce the volume of haemorrhage and risk of hypovolaemic cardiac arrest.

Early studies have shown promise with its use in exsanguinating pelvic trauma (Lendrum et al, 2019) alongside established methods of pelvic splinting and immobilisation of long-bone fractures. This demonstrates a significant survival improvement compared to other methods of controlling severe subdiaphragmatic haemorrhage, namely resuscitative thoracotomy (Brenner et al, 2018).

This procedure does have complications, particularly hypoperfusion and ischaemia distal to the site of balloon occlusion. REBOA is only used in zones 1 and 3 as mesenteric and renal ischaemia can result from complete aortic occlusion in zone 2 (Russo et al, 2016). This can also be caused by zone 1 placement; however, partial REBOA (P-REBOA) can be used to maintain low-volume flow to distal tissues whilst maintaining arterial control and preserving blood pressure (Lendrum et al, 2019).

The optimal inflation time of the balloon is an area of ongoing research, with Bekdache et al's (2019) systematic review stating the ideal time is 20 minutes, after which the catheter should be removed or an alternating inflation-deflation mode should be adopted (Bekdache et al, 2019).

Damage control resuscitation

Damage control resuscitation (DCR) is a term coined around the turn of the century, once again off the back of military experience. It describes a focus on the early control of bleeding, with particular attention being paid to coagulopathy, hypothermia and acidosis—an often fatal group of trauma sequelae (Rotondo and Zonies, 1997; Holcomb, 2007).

Coagulopathy in particular has historically been a troublesome issue for emergency doctors and trauma surgeons (Güven, 2017). Over the past two decades, the practice of haemostatic resuscitation has been developed specifically to counteract this. This involves a 1:1:1 ratio of packed red cells to fresh frozen plasma to platelets, and avoiding diluting crystalloid solutions: this has been demonstrated as the best approach to the immediate resuscitation of trauma patients (Van et al, 2017). For the purposes of this essay, DCR is being discussed separately from prehospital care although DCR is frequently initiated in this setting.

While maintaining ideal ratios of blood products is important, other crucial interventions are the use of tranexamic acid (TXA) and thromboelastography (TEG) to guide transfusion requirements.

With regards to TXA, it has been shown to reduce the risk of death from exsanguination with early administration in trauma (Roberts et al, 2013), traumatic brain injury (Cap, 2019) and post-partum haemorrhage (WOMAN Trial Collaborators, 2017). It acts through diminution of a maladaptive activation of the fibrinolytic pathway in response to injury that results in the breakdown of haemostatic clots, increasing the permeability of endothelial cells, oedema and inflammation (Cap, 2016).

TEG is a way of measuring the efficacy of blood coagulation and was developed at the University of Heidelberg in 1948. It overcomes the limitations of conventional testing of coagulation through platelet count, fibrinogen levels, prothrombin time and activated partial thromboplastin time, which are static, timely and often analysed in isolation. The main strengths of TEG are its dynamic analysis of clot formation, applicability as a bedside test, rapid turnaround of results and cost-effectiveness in identifying patients who are at a low risk of haemorrhage (Karon, 2014). Its main limitation is its inability to investigate hypercoagulable states postoperatively, which still require conventional haemostatic measurements (Bolliger et al, 2012).

An area of future exploration in DCR is the use of whole blood. Indeed, this is a return to past practice, with whole blood being the resuscitative tool of choice prior to the separation of blood components in 1965 (Barnes, 1980). The rationale behind this is that even a perfect 1:1:1 ratio of red cells, platelets and plasma delivers a solution that is anaemic (with a haemoglobin of approximately 9 g/dl), is thrombocytopenic (platelet count approximately 88 000/ml), has significantly decreased fibrinogen levels and has a 35% reduction in coagulation activity compared to whole blood (Zielinski et al, 2014; Van et al, 2017).

The use of whole blood in a military setting is supported by a wealth of evidence (Keneally et al, 2015). However, translation of this to the civilian population is limited because of concerns over acute haemolytic transfusion reactions. Low-titre anti-A and anti-B type O whole blood (LTOWB) has been demonstrated to be safe in military settings (Nadler et al, 2020). Another impediment to the widespread use of LTWOB in civilian trauma is a lack of consensus over the definition of low titre, with Norwegian and Swedish military services limiting immunoglobulin M (IgM) titres to <100, although some US divisions allow IgM titres as high as 256 (Fisher et al, 2015).

Despite this difficulty in civilian application, a 2019 survey revealed its use in one Norwegian and 24 US hospitals and two air ambulance services—one in Israel and Bart's Health NHS Trust in London (Yazer and Spinella, 2019). Unrefrigerated whole blood has been used as part of initial resuscitative efforts in Australia (Pivalizza et al, 2018). An aspect of this incorporation that needs clarification across healthcare providers is whole-blood wastage. This has been linked to its 21-day shelf life as well as potential unfamiliarity with its availability and hospital procedures surrounding its use (Pivalizza et al, 2018).

In the 2019 survey referred to above, some units had waste reduction strategies such as creating units of red cells once LTOWB reached its storage deadline. Other strategies included prehospital services returning LTOWB units to the hospital after 14 days, extending their shelf life to 35 days for trauma patients or reserving LTOWB between 21–35 days old for haemorrhaging non-trauma patients (Yazer and Spinella, 2020).

Larger studies investigating the use of whole blood against traditional component therapy are certain. Incorporating these into trauma algorithms could mitigate severe coagulopathy and significantly aid operative treatment of the most severely injured patients or prevent the need for surgery at all.

Interventional radiology

IR has an important role in trauma management. Training in transcatheter techniques and experience in multimodal imaging makes interventional radiologists capable of identifying significant internal haemorrhage and treating this in a timely manner.

For this to benefit patients, clear communication between members of the resuscitative multidisciplinary team, accurate initial assessment and prioritisation of injuries are essential.

IR therapies in trauma patients most commonly include:

  • Balloon occlusion proximal to a site of arterial injury while definitive surgery or endovascular intervention is planned
  • Transarterial embolisation: stopping haemorrhage and frequently averting the need for surgery, particularly in solid organ injuries (predominantly splenic and hepatic)
  • Use of stent grafts which can treat large-vessel disruption and potentially avoid difficult vascular repairs in a surgical field distorted by trauma (Gould and Vedantham, 2006).
  • IR has typically been reserved for haemodynamically stable trauma patients (Radwan and Abu-Zidan, 2006). However, a wealth of ongoing research is being carried out into the application of IR to the most severely injured unstable patients.

    An example of such work is Matsumoto et al's (2015) PRESTO protocol (prompt and rapid endovascular strategies in trauma occasions). This is a standardised algorithm activated when a resuscitation team receives a pre-alert from the prehospital emergency team. This protocol initiates prompt initial decision-making regarding the patient's suitability for IR, a rapid CT scan to identify severe pre-selected injuries in no more than 3 minutes and expert damage control IR (DCIR), with no individual procedure lasting more than 5 minutes. The aim is to change IR from being viewed as an adjunct to surgery in the trauma setting to it being a distinct, primary treatment method in itself (Matsumoto et al, 2015).

    Another proposed advance of IR's role in trauma is that of a hybrid or RAPTOR (resuscitation with angiography, percutaneous techniques and operative repair) suite. These are specialised units where CT scanning, IR facilities and surgical management can all be performed with minimal time-wasting as a patient is transferred from one location to another (D'Amours et al, 2013). Delay to radiological intervention has been repeatedly proven to increase mortality; Howell et al (2010) showed this effect can be as high as 47% for every hour delay (Howell et al, 2010).

    However there are clear difficulties associated with establishing these units; they come at enormous costs to healthcare providers, in terms of both designing and building them and staffing them. This cost is increased through maintenance of technology needed in these suites, and their reliance on multiple cooperating IT systems is another potential limitation. Further problems arise with loss of service provision through the extensive education of staff required, in the procedures, image analysis and the triaging of patients directly to the hybrid suites (Martin et al, 2012).

    With regards to triage, the lack of large-scale studies to guide this (as hybrid units have been introduced only recently) makes this difficult. An adaptation of existing triage tools to include when transfer to a RAPTOR suite would be appropriate would be an excellent addition to treatment algorithms in major trauma centres (Kinoshita et al, 2019).

    Conclusion

    The burden of exsanguinating patients on trauma systems worldwide is extensive and huge advancements in all aspects of trauma care have been made to minimise its impact.

    These begin at an organisational level with structuring services and can be seen throughout the patient journey: in prehospital care with the development of local haemostatic compounds for junctional haemorrhage and endovascular tools such as REBOA; the advancement of damage control resuscitation with a possible shift back to whole blood in the coming years; and the use of IR with its application broadening to a primary method of haemorrhage control for haemodynamically unstable patients.

    An interesting future direction is hybrid resuscitation suites, where operative and non-operative management are combined in a dedicated unit. These have clear limitations but have shown promising initial data with regards to 28-day mortality for trauma patients in Tokyo (Kinoshita et al, 2019). Further studies analysing cost-effectiveness will be required if they are to be used more widely.

    Key points

  • The largest impact on trauma morbidity and mortality has come through large-scale structural change such as the development of regional trauma networks with centralised skills
  • Trauma networks rely on accurate triage by ambulance teams; under-triage is dangerous for the most severely injured patients and over-triage leads to wasted resources and delays in time-critical interventions
  • Mechanical haemorrhage control through topical haemostatics and endovascular techniques is being transferred from military settings to civilian populations where studies are ongoing
  • Advances in damage control resuscitation (namely avoiding diluting crystalloid solutions and maintaining a 1:1:1 ratio of packed red cells to fresh frozen plasma to platelets) have clearly demonstrated survival benefits and should be adhered to stringently
  • Incorporating interventional radiology into treatment algorithms for haemodynamically well and, increasingly, haemodynamically unwell patients is becoming more common. Hybrid suites embody this in the most efficient way
  • CPD Reflection Questions

  • What problems do you think an exclusive trauma system creates in relation to the maintenance of health professionals' skills in non-major trauma centres?
  • Can you envisage any complications of using whole-blood transfusions in prehospital and inpatient settings not mentioned in this article?
  • How would a hybrid suite interfere with patient flow through an accident and emergency unit? How would prehospital teams have to adapt to this?