scholarly journals The management of critical bleeding in obstetrics

2013 ◽  
Vol 4 (3S) ◽  
pp. 41-51
Author(s):  
Marcus D. Lancé
Keyword(s):  
Vaginal Delivery ◽  
Post Partum ◽  
Damage Control ◽  
Visual Assessment ◽  
Fresh Frozen Plasma ◽  
Severe Bleeding ◽  
Trauma Patients ◽  
Excessive Bleeding ◽  
Risk Of Death ◽  
Critical Bleeding

Post-partum hemorrhage (PPH) is one of the most frequent causes of maternal death: worldwide it contributes for a 25% of deaths. The risk of death from pregnancy complications has decreased dramatically over the last few decades, but several evidences show they have not yet been reduced to a minimum. There is therefore the need for a further improvement in the quality of medical care. Purpose of this paper is to briefly outline an overview of the definition of PPH, with an illustration of the possible causes and treatments currently available. WHO defined PPH as excessive bleeding > 500 ml after vaginal delivery and severe PPH as bleeding in excess of 1,000 ml after vaginal delivery, but a variety of definitions for PPH have been proposed, yet no single satisfactory definition exists. Another crucial item regards the estimation of blood loss, too often based on a visual assessment and, therefore, inaccurate and minimized. However, in medical literature there are no specific classifications for severe bleeding in obstetrics. During pregnancy there are several changes in coagulation state: because haemostatic reference intervals are generally based on samples from non-pregnant women, this can cause a further difficulty in doing an accurate diagnosis and treatment of haemostatic disorders during pregnancy. In the treatment of critical bleeding in trauma patients have been developed some new insights that may be applied, at least partially, in the management of bleeding patients in obstetrics. In recent years it has been developed an approach called “Damage control resuscitation”, which combines to the surgery a medical treatment aimed at correcting the underlying coagulopathy. This approach is based on three items: minimise use of crystalloids and colloids; optimise fresh frozen plasma (FFP) to red blood cells (RBC) ratio; make an appropriate use of antifibrinolitic agents, fibrinogen and cryoprecipitate.

scholarly journals Predictive Factors for Massive Transfusion in Trauma: A Novel Clinical Score from an Italian Trauma Center and German Trauma Registry

2020 ◽  
Vol 9 (10) ◽  
pp. 3235
Author(s):  
Sara Giulia Cornero ◽  
Marc Maegele ◽  
Rolf Lefering ◽  
Claudia Abbati ◽  
Shailvi Gupta ◽  
...  
Keyword(s):  
Trauma Registry ◽  
Massive Transfusion ◽  
Damage Control ◽  
Area Under The Curve ◽  
Clinical Score ◽  
Limb Amputation ◽  
Predictive Score ◽  
Trauma Patients ◽  
Early Management ◽  
Critical Bleeding

Early management of critical bleeding and coagulopathy can improve patient survival. The aim of our study was to identify independent predictors of critical bleeding and to build a clinical score for early risk stratification. A prospective analysis was performed on a cohort of trauma patients with at least one hypotensive episode during pre-hospital (PH) care or in the Emergency Department (ED). Patients who received massive transfusion (MT+) (≥4 blood units during the first hour) were compared to those who did not (MT−). Hemodynamics, Glagow Coma Score (GCS), diagnostics and blood tests were evaluated. Using multivariate analysis, we created and validated a predictive score for MT+ patients. The predictive score was validated on a matched cohort of patients of the German Trauma Registry TR-DGU. One hundred thirty-nine patients were included. Independent predictors of MT+ included a prehospital (PH) GCS of 3, PH administration of tranexamic acid, hypotension and tachycardia upon admission, coagulopathy and injuries with significant bleeding such as limb amputation, hemoperitoneum, pelvic fracture, massive hemothorax. The derived predictive score revealed an area under the curve (AUC) of 0.854. Massive transfusion is essential to damage control resuscitation. Altered GCS, unstable hemodynamics, coagulopathy and bleeding injuries can allow early identification of patients at risk for critical hemorrhage.

Severe Bleeding in Pelvic Fractures: Considerations in Planning Damage Control

2018 ◽  
Vol 84 (2) ◽  
pp. 267-272 ◽  
Author(s):  
Jayun Cho ◽  
Elizabeth Benjamin ◽  
Kenji Inaba ◽  
Lydia Lam ◽  
Demetrios Demetriades
Keyword(s):  
Damage Control ◽  
Data Bank ◽  
Pelvic Fractures ◽  
Severe Bleeding ◽  
Trauma Patients ◽  
Pelvic Packing ◽  
National Trauma Data Bank ◽  
Abdominal Exploration ◽  
Control Procedures ◽  
Intraabdominal Injuries

Severe bleeding due to pelvic fractures may require damage control procedures, such as preperitoneal packing. In many cases, preperitoneal packing is performed without full abdominal exploration. There are concerns that such an approach may miss major iliac vascular injuries or other intraabdominal injuries. This analysis assessed the incidence of iliac vascular and intraabdominal injuries in patients with pelvic fractures. The National Trauma Data Bank was queried for blunt trauma patients. Patients with severe pelvic fractures were observed. Common or external iliac vascular lacerations (CEIVL) and associated intraabdominal injuries were recorded. The study comprised 42,122 patients with pelvic fractures, of which 3,221 (7.6%) were severe pelvic fractures. The incidence of CEIVL in patients with severe pelvic fractures was 10.7 per cent. Patient age greater than or equal to 65 years was an independent predictor of CEIVL. A total of 34.3 per cent of severe pelvic fracture patients had severe associated intraabdominal injuries, including injuries to the bladder (26.5%) and bowel (16.7%). Severe pelvic fractures are associated with a high incidence of iliac vascular and intraabdominal injuries. Preperitoneal pelvic packing without abdominal exploration may miss these injuries.

Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

2016 ◽  
Vol 82 (5) ◽  
pp. 427-432 ◽  
Author(s):  
Jason W. Smith ◽  
Nick Nash ◽  
Levi Procter ◽  
Matthew Benns ◽  
Glen A. Franklin ◽  
...  
Keyword(s):  
Damage Control ◽  
Penetrating Trauma ◽  
Damage Control Surgery ◽  
Abdominal Sepsis ◽  
Fascial Closure ◽  
Trauma Patients ◽  
Complication Rates ◽  
Emergency General Surgery ◽  
Risk Of Death ◽  
Abdominal Complication

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3–2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2–3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

scholarly journals Whole Blood for Blood Loss: Hemostatic Resuscitation in Damage Control

2020 ◽  
Author(s):  
Juan Carlos Salamea ◽  
Amber Himmler ◽  
Laura Isabel Valencia-Angel ◽  
Carlos Alberto Ordoñez ◽  
Michael Parra ◽  
...  
Keyword(s):  
Hemorrhagic Shock ◽  
Whole Blood ◽  
Damage Control ◽  
Fresh Frozen Plasma ◽  
Trauma Patients ◽  
Damage Control Resuscitation ◽  
Middle Income ◽  
Packed Red Blood Cells ◽  
Hemostatic Resuscitation ◽  
Fresh Frozen

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.

Introduction to the Sixth Edition of the JEVTM

2019 ◽  
Vol 3 (2) ◽  
Author(s):  
Igor M. Samokhvalov
Keyword(s):  
Post Partum ◽  
Damage Control ◽  
Interdisciplinary Approach ◽  
Simulation Models ◽  
Balloon Occlusion ◽  
Aortic Aneurysms ◽  
Sixth Edition ◽  
Bleeding Management ◽  
Aortic Balloon Occlusion ◽  
Poster Presentations

Dear Readers, Welcome to the sixth edition of the JEVTM! In 1866, the Great Russian surgeon and scientist Nikolai Pirogov wrote: “A new era for surgery will begin, if we can quickly and surely control the flow in a major artery without exploration and ligation”. This era has now arrived and it is called EVTM! Our mission has been to maximize the benefits of endovascular technologies for trauma and bleeding patients: from the first attempts of REBOA by Carl Hughes in the 1950s with hand-made aortic balloon occlusion catheters used in our department since the early 1990s to modern successful cases of out-of-hospital REBOA use in combat and civilian casualties for ruptured aneurysms, post-partum hemorrhage and trauma. In this edition, you will find articles related to a new strategy of damage control interventional radiology (DCIR), partial REBOA in elderly patients and in ruptured aortic aneurysms, thrombolysis for trauma-associated IVC thrombosis, simulation models for training of REBOA, contemporary utilization of Zone III REBOA and more. As a continuation of EVTM development, Russian surgeons, emergency physicians, anesthetists, and others will be involved in the world of EVTM, participating in expanding the horizons of trauma care and cultivating the endovascular mindset. Also published in this edition are some of the abstracts that will be presented at the EVTM conference in Russia, St. Petersburg (7/06/2019). More than 35 oral and 30 poster presentations will make this conference a scientific feast for our audience! By adopting these new techniques for bleeding management, we are following Pirogov’s motto – to achieve fast endovascular hemorrhage control – which can only be done as part of an interdisciplinary approach.   We look forward to seeing you in Saint Petersburg at the EVTM-Russia meeting! www.evtm.org

Racial and Sex Disparities in Trauma Outcomes Based on Geographical Region

2020 ◽  
pp. 000313482096006
Author(s):  
William Q. Duong ◽  
Areg Grigorian ◽  
Cyrus Farzaneh ◽  
Jeffry Nahmias ◽  
Theresa Chin ◽  
...  
Keyword(s):  
United States ◽  
The United States ◽  
Trauma Patients ◽  
Improvement Program ◽  
Trauma Outcomes ◽  
Risk Of Death ◽  
Hospital Access ◽  
Risk Of Mortality ◽  
Sex Disparities ◽  
Male Patients

Objectives Disparities in outcomes among trauma patients have been shown to be associated with race and sex. The purpose of this study was to analyze racial and sex mortality disparities in different regions of the United States, hypothesizing that the risk of mortality among black and Asian trauma patients, compared to white trauma patients, will be similar within all regions in the United States. Methods The Trauma Quality Improvement Program (2010-2016) was queried for adult trauma patients, separating by U.S. Census regions. Multivariable logistic regression analyses were performed for each region, controlling for known predictors of morbidity and mortality in trauma. Results Most trauma patients were treated in the South (n = 522 388, 40.7%). After risk adjustment, black trauma patients had a higher associated risk of death in all regions, except the Northeast, compared to white trauma patients. The highest associated risk of death for blacks (vs. whites) was in the Midwest (odds ratio [OR] 1.30, P < .001). Asian trauma patients only had a higher associated risk of death in the West (OR 1.39, P < .001). Male trauma patients, compared to women, had an increased associated risk of mortality in all four regions. Discussion This study found major differences in outcomes among different races within different regions of the United States. There was also both an increased rate and associated risk of mortality for male patients in all regions. Future prospective studies are needed to identify what regional differences in trauma systems including population density, transport times, hospital access, and other trauma resources explain these findings.

scholarly journals Pulmonary Hypertension Complicating Pregnancy

2021 ◽  
Author(s):  
Sheila Krishnan ◽  
Erin M. Fricke ◽  
Marcos Cordoba ◽  
Laurie A. Chalifoux ◽  
Reda E. Girgis
Keyword(s):  
Heart Failure ◽  
Pulmonary Hypertension ◽  
Post Partum ◽  
Severe Heart Failure ◽  
Neonatal Morbidity ◽  
Risk Of Death ◽  
Risk Condition ◽  
Pulmonary Arterial ◽  
Phosphodiesterase Type ◽  
Type V

Abstract Purpose of review This study aims to describe the pathophysiology of pregnancy in pulmonary hypertension (PH) and review recent literature on maternal and fetal outcomes. Recent findings There is an increasing number of pregnant women with PH. Maternal mortality in pulmonary arterial hypertension (PAH) ranges from 9 to 25%, most commonly from heart failure and arrythmias. The highest risk of death is peri-partum and post-partum. Fetal/neonatal morbidity and mortality are also substantial. There are high rates of prematurity, intrauterine growth retardation, and preeclampsia. Women should be referred to expert centers for management. Combination PAH therapy with parenteral prostacyclin and a phosphodiesterase type V inhibitor is recommended. Induced vaginal delivery is preferred, except in cases of severe heart failure or obstetric indications for cesarean section. Summary Despite advances in management, pregnancy in PAH remains a high-risk condition and should be prevented.

scholarly journals Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Derek J. Roberts ◽  
◽  
Niklas Bobrovitz ◽  
David A. Zygun ◽  
Andrew W. Kirkpatrick ◽  
...  
Keyword(s):  
Systematic Review ◽  
Damage Control ◽  
Penetrating Trauma ◽  
Damage Control Surgery ◽  
Trauma Patients ◽  
Clinical Scenario ◽  
Cross Sectional ◽  
Iliac Vessel ◽  
Civilian Trauma ◽  
Definitive Surgery

Abstract Background Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes). Methods We searched 11 databases (1950–April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. Results Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications. Conclusions Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

scholarly journals Independent Predictors of Mortality in Torso Trauma Injuries

2020 ◽  
Vol 9 (10) ◽  
pp. 3202
Author(s):  
Roberto Bini ◽  
Caterina Accardo ◽  
Stefano Granieri ◽  
Fabrizio Sammartano ◽  
Stefania Cimbanassi ◽  
...  
Keyword(s):  
Trauma Center ◽  
Injury Severity ◽  
Demographic Data ◽  
Trauma Patients ◽  
Related Condition ◽  
Predictors Of Mortality ◽  
Risk Of Death ◽  
Therapeutic Procedures ◽  
Torso Trauma ◽  
Enhanced Computed Tomography

Noncompressible torso injuries (NCTIs) represent a trauma-related condition with high lethality. This study’s aim was to identify potential prediction factors of mortality in this group of trauma patients at a Level 1 trauma center in Italy. Materials and Methods: A total of 777 patients who had sustained a noncompressible torso injury (NCTI) and were admitted to the Niguarda Trauma Center in Milan from 2010 to 2019 were included. Of these, 166 patients with a systolic blood pressure (SBP) <90 mmHg were considered to have a noncompressible torso hemorrhage (NCTH). Demographic data, mechanism of trauma, pre-hospital and in-hospital clinical conditions, diagnostic/therapeutic procedures, and survival outcome were retrospectively recorded. Results: Among the 777 patients, 69% were male and 90.2% sustained a blunt trauma with a median age of 43 years. The comparison between survivors and non-survivors pointed out a significantly lower pre-hospital Glasgow coma scale (GCS) and SBP (p < 0.001) in the latter group. The multivariate backward regression model identified age, pre-hospital GCS and injury severity score (ISS) (p < 0.001), pre-hospital SBP (p = 0.03), emergency department SBP (p = 0.039), performance of torso contrast enhanced computed tomography (CeCT) (p = 0.029), and base excess (BE) (p = 0.008) as independent predictors of mortality. Conclusions: Torso trauma patients who were hemodynamically unstable in both pre- and in-hospital phases with impaired GCS and BE had a greater risk of death. The detection of independent predictors of mortality allows for the timely identification of a subgroup of patients whose chances of survival are reduced.

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