The world of trauma working together

Peer reviewe

Operating Room Use of Hypertonic Solutions: A Clinical Review

Hyperosmotic-hyperoncotic solutions have been widely used during prehospital care of trauma patients and have shown positive hemodynamic effects. Recently, there has been a growing interest in intra-operative use of hypertonic solutions. We reviewed 30 clinical studies on the use of hypertonic saline solutions during surgeries, with the majority being cardiac surgeries. Reduced positive fluid balance, increased cardiac index, and decreased systemic vascular resistance were the main beneficial effects of using hypertonic solutions in this population. Well-designed clinical trials are highly needed, particularly in aortic aneurysm repair surgeries, where hypertonic solutions have shown many beneficial effects. Examining the immunomodulatory effects of hypertonic solutions should also be a priority in future studies

COAGULOPATIA NO TRAUMA

Trauma is one of the most important causes of deaths worldwide. Massive bleeding is the leading cause of trauma deaths in the first 24 hours following an injury. Major trauma patients frequently develop coagulopathy, which is related to huge bleedings, fluid therapy with crystalloids and red blood cells, acidosis and hypothermia. The control of this situation is a challenge to surgeons and intensivists. In addition, trauma victims are one of the most important consumers of blood components. Recently, the adequacy of this massive transfusion has been put into question, particularly due to the lack of well-developed and clinically-proved guidelines. The objective of this article is to provide an overview of the pathophysiology of the trauma coagulopathy, discussing current strategies available for its management and new developments in the field.Trauma é uma das principais causas de mortalidade no mundo. A principal causa de óbitos das vítimas de trauma, nas primeiras 24 horas após a lesão, é o sangramento maciço. Os pacientes politraumatizados podem desenvolver graves distúrbios de coagulação relacionados à perda de grandes volumes de sangue e fatores de coagulação, à reposição volêmica com cristalóides e com concentrados de hemácias, à acidose e à hipotermia. O controle deste tipo de situação tem sido um grande desafio para cirurgiões e intensivistas. Além disto, as vítimas de trauma formam um dos maiores grupos de consumidores de sangue e seus derivados. Recentemente, a adequação destes grandes volumes de transfusão tem sido questionada, principalmente em decorrência da ausência de protocolos bem definidos e testados clinicamente. O objetivo deste artigo foi rever a literatura atual conceituando coagulopatia do trauma e descrevendo as mais recentes orientações para a hemoterapia direcionada às vitimas de trauma

Classification of Liver Trauma

The classification of liver injuries is important for clinical practice, clinical research and quality assurance activities. The Organ Injury Scaling (OIS) Committee of the American Association for the Surgery of Trauma proposed the OIS for liver trauma in 1989. The purpose ofthe present study was to apply this scale to a cohort ofliver trauma patients managed at a single Canadian trauma centre from January 1987 to June 1992.170 study patients were identified and reviewed. The mean age was 30, with 69% male and a mean ISS of 33.90% had a blunt mechanism ofinjury. The 170 patients were categorized into the 60IS grades ofliver injury. The number of units of blood transfused, the magnitude of the operative treatment required, the liver-related complications and the liver-related mortality correlated well with the OIS grade. The OIS grade was unable to predict the need for laparotomy or the length of stay in hospital. We conclude that the OIS is a useful, practical and important tool for the categorization of liver injuries, and it may prove to be the universally accepted classification scheme in liver trauma

Qatar Health 2021: An online conference to prepare for a mass gathering sporting event while still addressing the pandemic

It feels like yesterday that we wrote the editorial related to the previous issue of the Qatar Health 2020 Conference! 1 . 2020 is clearly a year to remember globally as a challenging one and this probably contributed to time passing so rapidly, keeping everyone so busy caring for patients and conducting research 2 . COVID-19 has had a big impact on all aspects of our lives, from the way we deliver patient care and work, to how we socialize and plan for the future in general. The past year has certainly provided an opportunity for the State of Qatar to demonstrate its resilience, its ability to rapidly adapt to new circumstances, and to find effective solutions to new problems 3,4 . Although very concerned by the current pandemic, our focus needs to also concentrate on the forthcoming FIFA World Cup in 2022 and every possible health related aspects, to ensure the event is safely hosted for everyone’s enjoyment. This has been clearly reflected in the Qatar Health 2021 conference program and call for abstracts (Table 1) which was organized into four parallel tracks fully hosted online for everyone’s safety. This issue of the Journal of Emergency Medicine, Trauma and Acute Care contains an extensive selection of 38 out of the 94 abstracts that have been accepted for oral or poster presentation during the conference. The abstract themes are summarized in Table 2 and range from the impact of the pandemic on delivering primary care to Qatar’s preparedness to dealing with hazardous and chemical, biological, radiological and nuclear incidents 5,6 . Notably 48 (51.06%) of the abstract titles contained the word COVID-19 or pandemic while only 4 abstracts (4.25%) were related to mass gatherings and sporting events. The later topics were primarily covered by multiple invited speakers with the relevant experience and proved to be the most attended conference sessions. It is worth noticing that the event attracted just over of 5,400 delegates and speakers from a total of 40 countries and has received highly positive feedback. We look forward to welcoming everyone again next year as we come closer to the FIFA World Cup 2022, with many more topics, partner organizations, and attendees

Recombinant factor VIIa is associated with an improved 24-hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients

OBJECTIVE: To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications. INTRODUCTION: Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use. METHODS: Consecutive massively transfused (>; 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24-hour and in-hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24-hour and in-hospital survival. RESULTS: Three-hundred and twenty-eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non-rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24-hour survival (odds ratio (OR) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (OR = 1.63; confidence interval 0.79-3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events. CONCLUSIONS: Despite being associated with improved 24-hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients

Recombinant factor VIIA is associated with an improved 24‐hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients

OBJECTIVE: To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications. INTRODUCTION: Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use. METHODS: Consecutive massively transfused (> 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24-hour and in-hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24-hour and in-hospital survival. RESULTS: Three-hundred and twenty-eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non-rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24-hour survival (odds ratio (OR) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (OR = 1.63; confidence interval 0.79-3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events. CONCLUSIONS: Despite being associated with improved 24-hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients

Qatar Health 2022: Preparing for the 2022 World Cup and the response to pandemics in Qatar – a multidisciplinary team approach

Welcome to this special issue of JEMTAC dedicated to the selection of 74 abstracts submitted to the Qatar Health 2022 online conference. The years are passing and the COVID-19 pandemic situation has not changed much globally. Although new vaccines have been developed and several restrictive measures have been rolled out in most countries to protect people, thousands are still succumbing to the effects of COVID-19 1,2 . Similar to the Qatar Health 2021 conference 3 , among the abstract submissions, there is still much emphasis on how healthcare systems and services are dealing with the situation to mitigate the spread of the disease among patients and healthcare professionals, while still trying to deliver physical or mental care to those in need 4–6 . It is also important to point out that the same needs and concerns apply to both the general public as well as the healthcare workforce 7,8 . From a preparedness point of view, continuing professional development and testing of new processes and facilities are key to ensuring clinicians are ready to take on new roles in new environments, and that technology can play a significant role in a pandemic context 9–11 . This is not only true in relation to clinical facilities, but as Qatar prepares to host the 2022 World Cup, it is also highly relevant to sporting events, during which multiple agencies need to work together collaboratively and as a multidisciplinary team as per the theme of Qatar Health 2022 and the 2nd Qatar Public Health Conference 12–13

Clinical review: Fresh frozen plasma in massive bleedings - more questions than answers

Fresh frozen plasma (FFP) is indicated for the management of massive bleedings. Recent audits suggest physician knowledge of FFP is inadequate and half of the FFP transfused in critical care is inappropriate. Trauma is among the largest consumers of FFP. Current trauma resuscitation guidelines recommend FFP to correct coagulopathy only after diagnosed by laboratory tests, often when overt dilutional coagulopathy already exists. The evidence supporting these guidelines is limited and bleeding remains a major cause of trauma-related death. Recent studies demonstrated that coagulopathy occurs early in trauma. A novel early formula-driven haemostatic resuscitation proposes addressing coagulopathy early in massive bleedings with FFP at a near 1:1 ratio with red blood cells. Recent retrospective reports suggest such strategy significantly reduces mortality, and its use is gradually expanding to nontraumatic bleedings in critical care. The supporting studies, however, have bias limiting the interpretation of the results. Furthermore, logistical considerations including need for immediately available universal donor AB plasma, short life after thawing, potential waste and transfusion-associated complications have challenged its implementation. The present review focuses on FFP transfusion in massive bleeding and critically appraises the evidence on formula-driven resuscitation, providing resources to allow clinicians to develop informed opinion, given the current deficient and conflicting evidence