Emergency Department Crowding and the Performance of Damage Control Resuscitation in Major Trauma Patients With Hemorrhagic Shock

Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.

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Impact of 24/7 Onsite Emergency Radiology Staff Coverage on Emergency Department Workflow

Canadian Association of Radiologists Journal ◽

10.1177/08465371211023861 ◽

2021 ◽

pp. 084653712110238

Author(s):

Francesco Macri ◽

Bonnie T. Niu ◽

Shannon Erdelyi ◽

John R. Mayo ◽

Faisal Khosa ◽

...

Keyword(s):

Emergency Department ◽

Major Trauma ◽

Patient Flow ◽

Interrupted Time Series ◽

Trauma Patients ◽

Linear Regression Models ◽

High Acuity ◽

Time Series Approach ◽

Comparison Series ◽

The Impact

Purpose: Assess the impact of 24/7/365 emergency trauma radiology (ETR) coverage on Emergency Department (ED) patient flow in an urban, quaternary-care teaching hospital. Methods: Patient ED visit and imaging information were extracted from the hospital patient care information system for 2008 to 2018. An interrupted time-series approach with a comparison group was used to study the impact of 24/7/365 ETR on average monthly ED length of stay (ED-LOS) and Emergency Physician to disposition time (EP-DISP). Linear regression models were fit with abrupt and permanent interrupts for 24/7/365 ETR, a coefficient for comparison series and a SARIMA error term; subgroup analyses were performed by patient arrival time, imaging type and chief complaint. Results: During the study period, there were 949,029 ED visits and 739,796 diagnostic tests. Following implementation of 24/7/365 coverage, we found a significant decrease in EP-DISP time for patients requiring only radiographs (-29 min;95%CI:-52,-6) and a significant increase in EP-DISP time for major trauma patients (46 min;95%CI:13,79). No significant change in patient throughput was observed during evening hours for any patient subgroup. For overnight patients, there was a reduction in EP-DISP for patients with symptoms consistent with stroke (-78 min;95%CI:-131,-24) and for high acuity patients who required imaging (-33 min;95%CI:-57,-10). Changes in ED-LOS followed a similar pattern. Conclusions: At our institution, 24/7/365 in-house ETR staff radiology coverage was associated with improved ED flow for patients requiring only radiographs and for overnight stroke and high acuity patients. Major trauma patients spent more time in the ED, perhaps reflecting the required multidisciplinary management.

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Phase 0: Damage Control Resuscitation in the Pre-hospital and Emergency Department Settings

Damage Control Management in the Polytrauma Patient ◽

10.1007/978-0-387-89508-6_8 ◽

2010 ◽

pp. 101-122

Author(s):

Andrew B. Peitzman ◽

Babak Sarani

Keyword(s):

Emergency Department ◽

Damage Control ◽

Damage Control Resuscitation ◽

Phase 0

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Is Whole Body CT Safe and Cost Effective in Managing MT (Major Trauma) Patients in the Emergency Department (ED)?

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2012.09.119 ◽

2012 ◽

Vol 43 (5) ◽

pp. 939

Author(s):

M. Majeed ◽

D. Yeo ◽

J. Kayani

Keyword(s):

Emergency Department ◽

Major Trauma ◽

Cost Effective ◽

Whole Body ◽

Trauma Patients ◽

Whole Body Ct ◽

Body Ct

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Triaging older major trauma patients in the emergency department: an observational study

Emergency Medicine Journal ◽

10.1136/emermed-2013-203191 ◽

2014 ◽

Vol 32 (4) ◽

pp. 281-286 ◽

Cited By ~ 5

Author(s):

William Lukin ◽

Jaimi H Greenslade ◽

Kevin Chu ◽

Jacelle Lang ◽

Anthony F T Brown

Keyword(s):

Emergency Department ◽

Observational Study ◽

Major Trauma ◽

Trauma Patients

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Outcomes after Massive Transfusion in Nontrauma Patients in the Era of Damage Control Resuscitation

The American Surgeon ◽

10.1177/000313481207800622 ◽

2012 ◽

Vol 78 (6) ◽

pp. 679-684 ◽

Cited By ~ 15

Author(s):

Bryan C. Morse ◽

Christopher J. Dente ◽

Erica I. Hodgman ◽

Beth H. Shaz ◽

Anne Winkler ◽

...

Keyword(s):

Trauma Center ◽

Massive Transfusion ◽

Damage Control ◽

Underlying Disease ◽

Base Deficit ◽

Trauma Patients ◽

Damage Control Resuscitation ◽

Packed Red Blood Cells ◽

Level I ◽

Initial Base

There are little data regarding the use of massive transfusion protocols (MTP) outside of the trauma setting. This study compares the use of an MTP between trauma and non-trauma (NT) patients. Data were collected for trauma and NT patients from the prospectively maintained MTP database at a Level I trauma center over a 4-year period. Massive transfusion was defined as $ 10 units packed red blood cells (PRBCs) in a 24-hour period. Of 439 MTP activations, 37 (8%) were NT patients (64% male; mean age = 51 years, initial base deficit = -10.8). Activations were for gastrointestinal bleeding (n = 18), bleeding during surgery (n = 13), obstetrical complications (n = 5), and ruptured aortic aneurysm (n = 1). Over-activation of MTP (< 10 units PRBCs/24 hours) was higher in NT than trauma patients (19/37, 51% vs 118/284, 29%, P < 0.01). For massive transfusion patients, 24-hour mortality was higher in NT compared with trauma patients (10/17, 59% vs 100/284, 35%, P = 0.05), but there was no difference in 30-day mortality (10/17, 59% vs 144/284, 51%, P = 0.51). With over-activation in 51% of NT patients, MTP usage outside of trauma is inefficient. Outcomes in NT patients were worse than trauma patients, which may be related to the underlying disease processes.

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Damage Control Resuscitation Protocol and the Management of Open Abdomens in Trauma Patients

The American Surgeon ◽

10.1177/000313481408000825 ◽

2014 ◽

Vol 80 (8) ◽

pp. 768-775 ◽

Cited By ~ 11

Author(s):

Matthew Bradley ◽

Samuel Galvagno ◽

Amit Dhanda ◽

Carlos Rodriguez ◽

Margaret Lauerman ◽

...

Keyword(s):

Logistic Regression ◽

Injury Severity ◽

Damage Control ◽

Fascial Closure ◽

Trauma Patients ◽

Damage Control Resuscitation ◽

Total Blood ◽

Independent Risk Factors ◽

Student’S T ◽

Admission Glasgow Coma Scale

Although the use of damage control laparotomy (DCL) is well established, the effect of damage control resuscitation (DCR) on the management of open abdomens is relatively poorly studied. The aim of the present study was to determine the predictors for failure to achieve primary fascial closure (PFC) after DCL in the setting of a massive transfusion (MT) and DCR. This is a retrospective review over a 12-year period of all patients that underwent MT and DCL. Patients who achieved PFC were compared with those who did not (NPFC). Student's t tests were used to compare the two groups. A multiple logistic regression model was performed to identify independent risk factors for failure to attain PFC. Of 174 patients, 101 achieved PFC. Mean (6 standard deviation) age was 35.6 ± 14.9 years for PFC and 36.3 ± 14.0 years for NPFC ( P = 0.75). Admission Glasgow Coma Scale score was 11.4 ± 4.6 for PFC and 10.6 ± 5.0 for NPFC ( P = 0.25). Initial lactate (7.3 ± 3.8 vs 7.7 ± 4.1, P = 0.50), hemoglobin (11.3 ± 1.9 vs 11.0 ± 2.2, P = 0.43), systolic blood pressure (108 ± 44 vs 107 ± 35, P = 0.82), Injury Severity Score (34 ± 14 vs 36 ± 15, P = 0.32), and abdominal Abbreviated Injury Score (3.6 ± 1.1 vs 3.9 ± 1.0, P = 0.13) were similar between the two groups. There was no difference in total blood products administered at 24 hours (46 ± 26 vs 49 ± 29 units, P = 0.45). Logistic regression identified increasing volume of crystalloid at 24 hours (odds ratio, 0.86; 95% confidence interval, 0.74 to 0.99; P = 0.047), earlier operative year (2.1; 1.52 to 2.91; P < 0.001), and increased number of procedures (0.32, 0.18 to 0.58; P < 0.001) as independent predictors for failure to obtain PFC. Injury severity is not associated with failure to achieve PFC, whereas administration of large-volume crystalloid resuscitation, increasing number procedures, and earlier year of DCL are independent predictors for failure to achieve PFC. Application of DCR to DCL techniques results in an improvement in ability to achieve PFC.

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