Age, blood transfusion, and survival after trauma

Blood transfusion affects outcomes after trauma, but whether elderly patients are disproportionately affected remains unknown. To determine the possible interaction between age, packed cell transfusion volume (PCTV), and mortality after injury, we designed a 6-year retrospective review (January 1995 through December 2000) of patients > or = 16 years of age who received blood transfusion within the first 24 hours after injury. One thousand three hundred twelve patients > or = 16 years of age admitted to our trauma center received packed red blood cells in the initial 24 hours after admission. Of the 1312 patients, 1028 (78%) were < or = 55 years and 284 (22%) were > 55 years of age, and overall mortality was 21.2 per cent. Age, Injury Severity Score (ISS) Glasbow Coma Scale (GCS), and PCTV emerged as independent predictors of mortality. PCTV for elderly survivors (4.6 units) was significantly less than that of younger survivors (6.7 units). Furthermore, mean PCTV for all survivors decreased progressively with advancing age. No patient >75 years with a PCTV > 12 units survived. Age and PCTV act independently, yet synergistically to increase mortality following injury.     

Erythropoietin in a patient following multiple trauma

We report on a Jehovah's Witness who had severe blood loss following major trauma. The problems of her management without blood transfusion, and with the use of recombinant human erythropoietin therapy for severe anaemia, are described.     

Initial hematocrit predicts the use of blood transfusion in the pediatric trauma patient

PurposeInitial hematocrit (Hct) is generally not considered a marker of acute blood loss because it is assumed that physiologic response of fluid conservation to hemorrhage is delayed. We challenged this idea by theorizing that admission Hct correlates with conventional signs of shock and predicts the use of blood transfusion during resuscitation of pediatric trauma patients.MethodsData from 1928 pediatric admissions (< 18 years) at a Level I trauma center (2000–2012) were compared using standard statistical analyses and logistic regression modeling to identify factors associated with blood transfusion during initial trauma resuscitation.ResultsOverall mortality rate was 3.5%, with a transfusion rate of 10.7%. Factors significantly associated with transfusion were initial Hct, Glasgow Coma Score, base deficit, and injury severity score (all p < 0.001). Initial Hct is a stronger predictor for transfusion (area under receiver operator curve (AUC: 0.728) compared to age-specific tachycardia (AUC: 0.689), age-specific hypotension (AUC: 0.673), and altered mental status (AUC: 0.654)). On multivariate analysis, initial Hct was an independent predictor (OR [95% CI]: 2.94 [1.56, 5.52]) along with hypotension (6.37 [2.95, 13.8]), base deficit (4.14 [1.38, 12.4]), and tachycardia (3.07 [1.62, 5.81]).ConclusionsInitial Hct correlates significantly with conventional signs of shock and is a strong independent predictor for blood transfusion with better predictability than other clinical factors.     

Bladder involvement in HTLV-I associated myelopathy

The HTLV-I infection was endemic in south western Kyushu. This human T-lymphotropic virus type I may cause HTLV-I associated myelopathy (HAM), a neurological disease characterized by a spastic paraparesis. And one of the minor diagnostic features of HAM is the presence of cystorectal disturbance. We experienced 35 HAM patients with a neurogenic bladder. A gradually progressive contracted bladder was observed in 3 of them. The main pathological finding in these patients was submucosal infiltration of lymphocytes. These findings suggest that immunologic mechanisms account for the development of bladder lesions.     

Neuroleptic malignant syndrome in a multiple trauma patient

Neuroleptic malignant syndrome is a little-known adverse reaction to neuroleptic administration characterized by hyperpyrexia, leukocytosis, creatine kinase elevations, muscular rigidity, autonomic dysfunction, and alterations in level of consciousness. Neuroleptic malignant syndrome has an associated 20% mortality but can be reversed when treated with neuroleptic discontinuation and administration of bromocriptine and dantrolene. Early diagnosis in the trauma unit may prevent an extensive workup for presumed sepsis. To our knowledge, neuroleptic malignant syndrome has not previously been reported in a multiple trauma patients.     

1例严重多发伤术后并发肠漏患者的护理

对1例严重多发伤术后并发肠漏患者进行精心护理,针对患者12根管道,采取标识管道、制定引流护理记录单;对肠漏冲洗采用自制多套管吸引、保持合适压力等措施;做好胆汁回输及基础护理等。结果患者恢复良好。提出肠漏虽是临床较常见的并发症,但护理人员需在实践中针对个体患者不断改进和总结,以促进患者康复。     

Coagulopathy and blood component transfusion in trauma

Trauma is a serious global health problem, accounting for approximatelyone in 10 deaths worldwide. Uncontrollable bleeding accountsfor 39% of trauma-related deaths and is the leading cause ofpotentially preventable death in patients with major trauma.While bleeding from vascular injury can usually be repairedsurgically, coagulopathy-related bleeding is often more difficultto manage and may also mask the site of vascular injury. Thecauses of coagulopathy in patients with severe trauma are multifactorial,including consumption and dilution of platelets and coagulationfactors, as well as dysfunction of platelets and the coagulationsystem. The interplay between hypothermia, acidosis and progressivecoagulopathy, referred to as the ‘lethal triad’,often results in exsanguination. Current management of coagulopathy-relatedbleeding is based on blood component replacement therapy. However,there is a limit on the level of haemostasis that can be restoredby replacement therapy. In addition, there is evidence thattransfusion of red blood cells immediately after injury increasesthe incidence of post-injury infection and multiple organ failure.Strategies to prevent significant coagulopathy and to controlcritical bleeding effectively in the presence of coagulopathymay decrease the requirement for blood transfusion, therebyimproving clinical outcome of patients with major trauma.     

Intraoperative blood transfusion in a child with blunt abdominal trauma

Pediatric transfusion therapy is complex since there is a remarkable physiological change from neonate to child. Here we report the blood transfusion management of a 6-year-old male child after abdominal trauma. Particular normovolemia with ringer/hetastarch, the estimation of the maximal allowable blood loss, target transfusion hematocrit, transfusion with platelets and FFP are discussed.     

Massive blood transfusion and trauma resuscitation

AIMS: To review the massive transfusion practice at a Level I adult Trauma Centre during initial trauma reception and resuscitation. METHODS: All trauma patients presenting to The Alfred Emergency & Trauma Centre and receiving a transfusion of five units or more of packed red blood cells within 4h of presentation over a 26-month period were included in this study. Patient demographics, clinical characteristics, injuries, surgical management and volume of blood transfused were analysed with mortality as the primary endpoint. Initial clinical features and injuries predictive of massive transfusion were also analysed. RESULTS: There were 119 patients who received a transfusion of five units or more of packed red blood cells (PRBCs) within 4h of presentation. The median Injury Severity Score of this group of patients was 34.0 (IQR 26-48) and mortality was 27.7%. The median number of packed red blood cell transfused was 8.0 (IQR 6-14) in the 1st 4h. Initial clinical features and injuries independently associated with a larger volume of blood transfused were initial hypotension, fractures of the pelvis, kidney injuries, initial acidaemia, and thrombocytopaenia. The Injury Severity Score, initial coagulopathy measured by APTT and the presence of head injuries were the independent predictors of mortality. CONCLUSIONS: The volume of blood transfused during trauma resuscitation was not found to be an independent predictor of mortality. Prospective studies into transfusion practice and clinical features of patients during the trauma resuscitation phase requiring massive transfusion are needed to establish evidence-based guidelines for massive transfusion.     

Reversible posterior leukoencephalopathy syndrome after blood transfusion in a patient with end-stage renal disease

A 42-year-old female end-stage renal disease (ESRD) patient with reversible posterior leukoencephalopathy syndrome (RPLS) post-transfusion during initiation of hemodialysis is reported. Eleven days after the onset of illness, we diagnosed encephalopathy as a grand mal seizure resulting from diffuse cerebral edema. One reason for the delayed diagnosis was that her symptom, a throbbing headache that occurred during her first dialysis, indicated dialysis disequilibrium syndrome. We must bear in mind that a small amount of transfusion could cause RPLS even during the first dialysis. To our knowledge, this is the first case report on RPLS after blood transfusion in an ESRD patient.     

Two cases of HTLV-I associated myelopathy (HAM) after cardiac operation

Sixty-one and 51-year-old males had progressive walk disturbance after cardiac operations at the intervals of 1 and 2 years. They had received blood transfusion at their operations. Physical examination revealed spastic paraparesis, sensory disturbance of the lower and rectobladder disorder. High titers of anti-Human T-lymphotrophic Virus type-I (HTLV-I) antibody were found in sera and CNF in both cases. They were diagnosed as HTLV-I associated myelopathy (HAM). Because they lived in Aichi Prefecture where the virus is non-epidemic, they were possibly infected through the blood transfusion at their operations. For prevention of HAM, the anti-HTLV-I antibody of all donor blood should be checked before transfusion.     

Pulmonary pasteurellosis in a young patient with multiple trauma]

A case is reported of an 18-year-old male patient who had a road traffic accident, with head and chest injuries. The patient was admitted to the surgical intensive care unit 24 h later because of an alteration of his level of consciousness. He required artificial ventilation. Five days later, he developed right-sided lower lobe pneumonia, treated with positive end-expiratory pressure. A Gram negative organism was found on bronchial brushing, but not in haemocultures. It was identified as Pasteurella multocida, sensitive to beta-lactamines, but not to amikacin. Cefotaxime, which had been started immediately after the arrival of the Gram stain result, was continued. Artificial ventilation was discontinued on day 12, and the patient left the unit on day 15. The patient was probably a P. multocida carrier, being in close contact with animals before his accident. This bacteria is often found in infected animal bite wounds. Pneumonia due to this bacteria usually occurs in immunodepressed patients, which was not the case here.     

Laryngeal fracture in the multiple trauma patient

The Cincinnati General Hospital experience with early diagnosis and repair of laryngeal fractures in the multiple trauma patient is presented. The results demonstrate the feasibility and value of early laryngeal diagnosis and repair in these severely traumatized patients.     

Bilateral perilunar fracture luxation in a patient with multiple trauma

We present the case of a 37-year-old, multiply injured man who sustained a bilateral perilunar fracture dislocation after a 6?m fall. The fracture dislocations were diagnosed by standard radiographs. The right side was initially treated by closed reduction and external fixation, the left side by closed reduction and splint immobilization. The patient received definite treatment 5?days after the initial injury by open reduction and internal fixation using suture anchors and temporary K-wire fixation which were removed after 6?weeks. The patient achieved almost a full range of motion in both hands and went back to his work as a roofer 5?months after surgery.     

自体血回输应用于严重创伤的研究进展

背景 每年全球死于严重创伤的人数高达上百万人.严重创伤后的大出血不仅是常见致死原因,而且是住院早期死亡的首要原因.常见及首要的处理就是输注大量血液成分. 目的 对不同严重创伤手术中自体血回收后的血液成分进行分析,为临床上自体血回输(autotransfusion,AT)的合理运用提供参考. 内容 介绍AT的发展历史及目前使用情况,回顾国内外相关研究,对不同部位创伤应用AT治疗后的血液成分进行分析,探讨其对红细胞功能、炎症反应、凝血功能的影响,简述近期研究热点. 趋向 AT能缓解用血紧张的情况,且随着对其深入研究,患者将获得更大的临床效益.     

Immunoparalysis after multiple trauma

The immunological sequelae following multiple trauma constitute an ongoing challenge in critical care management. The overall immune response to multiple trauma is a multilevel complex interdependently involving neurohormonal, cellular and haemodynamic factors. Immunoparalysis is characterised by a reduced capacity to present antigens via downregulated HLA-DR and an unbalanced monocyte–T cell interaction. Trauma-induced death of functionally conducive immune cells in the early recovery phase is significant in the emergence of posttraumatic multiple organ dysfunction or failure. Novel findings may contribute to more appropriate immunomonitoring and improved treatment. We must consider the preservation and support of immune function as the ultimate therapeutic goal, which may override the current strategy of simply antagonising excessive pro- or anti-inflammatory immune responses of the severely injured person. This review focuses on the injury-induced conduct of key immune effector cells and associated effects promoting immunoparalysis after multiple trauma.     

Massive transfusion in the trauma patient: Continuing Professional Development

Purpose

Massive transfusion has recently been given a dynamic definition, namely, the replacement of more than four red cell concentrates within an hour. The purpose of this continuing professional development module is to review the pathophysiology of hemorrhagic shock in the trauma patient and the current management strategies of the massively bleeding trauma patient.

Principal findings

The massively bleeding trauma patient requires concurrent hemorrhage control and blood replacement therapy. Although there are many complications of massive transfusions, such as acid-base disturbances, electrolyte abnormalities, and hypothermia, perhaps the most difficult aspect to manage is acute trauma coagulopathy. Historically, coagulopathy was attributed to dilution of coagulation factors; however, recent accumulated evidence indicates that it is a multifactorial process associated with hypoperfusion, factor consumption, and hyperfibrinolysis. In an attempt to minimize acute trauma coagulopathy, massive transfusion protocols with equal ratios of red cell concentrates, frozen plasma, and platelets have been proposed. This type of hemostatic resuscitation, with near equal ratios of blood and blood products, has improved survival, but it is not without risk. In addition to the rapid and effective restoration of blood volume, the specific goal of transfusion management should be to maintain the patient??s oxygen carrying capacity, hemostasis, and biochemistry.

Conclusion

The current literature does not permit firm conclusions to be drawn regarding optimal transfusion ratios. It remains appropriate, however, to devise a massive transfusion protocol at the institutional level that provides treating physicians with rapid delivery of a reasonable initial ratio of products. This would permit patient-centred management with an emphasis on surgical control of bleeding, maintenance of normothermia, avoidance of electrolyte abnormalities, acid-base balance, and the timely delivery of blood products.

Objectives

After reading this module, the reader should be able to:

1. Enumerate the complications associated with massive transfusion in the trauma context;
2. Understand how the coagulopathy present in the trauma patient differs from that seen in the elective setting;
3. Identify the modifications suggested by the recent literature for the management of massive transfusion in the trauma setting;
4. Appreciate the evidence for the institution of massive transfusion protocols.