JC: Why do bleeding trauma patients die? St Emlyn’s

Just a quick JC blog post this week to point you to an editorial written by Karim Brohi and John Holcomb on why, and when, patients die of trauma. The editorial appears in Intensive Care Medicine1 and is currently open access. As always we recommend you read the article yourself in order to form your own opinion. It’s a short article, but well worth a read IMHO.

This is something I’ve chatted to Karim about several times over the last year or so and it’s really interesting stuff. Firstly it’s important that we recognise that we have seen a reduction in the number of deaths from trauma. That’s a great thing of course, but we should not be complacent. It’s also worth looking at where and how patients die. The key graph from the editorial is shown below and is based on data from the Royal London Hospital2.

The data seems to be suggesting that changes to how we manage trauma have altered where, and perhaps why people die.

Overall we are getting better at the resuscitation phases of trauma management. Prehospital care improvements, such as the use of prehospital blood3, has led to an increase in the number of patients reaching hospital alive4. Improvements in our resuscitation practice, such as TXA5 and the regionalisation of trauma6,7 seem to suggest a signifcant difference in prehopsital deaths, but more people arriving in hospital alive means that a greater number of patients die in the first few hours.

Improved surgical techniques and better surgical practice have resulted in more patients reaching the ICU alive with fewer patients who survive the first 3 hours dying on the first day and making it to the ICU.

However, getting to the ICU is not an end point for these patients. In this editorial Karim and John show how we now have an increase in later deaths. The data here is really interesting and perhaps surprising. Despite patients arriving in the ICU in better condition than previously there are still significant numbers of patients dying ‘late’ from complications of bleeding. We now also know that the mortality from trauma laparotomy is essentially unchanged for many years8,9, the new TELA study is specifically addressing this10.

The editorial explores potential reasons for these late deaths. Describing a complex mixture of cardiovascular failure in the first few hours or days and leading to progressive requirements for inotropes and organ support. The second group of deaths occurs later and is described as persistent inflammation, immunosuppression and catabolism syndrome11,12.

It’s worth following the conversation on twitter too regarding this editorial as others suggest potential mechanisms and reasons, but the bottom line is that we don’t yet fully understand the mechanism of late death in many patients.

What does this mean for us?

My first take home message from this paper is that we to remind ourselves that it is trauma ‘systems’ that make a difference and that we need to consider how changes in one area might impact another. The increase in early hospital deaths is probably a result of improved prehospital care, and is perhaps one of the reasons why the Royal London Hospital had terrible outcomes reported by the TARN network for many years13. The RLH received patients from London HEMS who were miles ahead of prehospital practice as compared to the rest of the UK for many, many years. As a result a greater number of patients arrived at RLH alive as compared to other hospitals. My assumption is that TARN is unable to account for this and so bizarrely may attribute better hospital scores to localities with less advanced pre-hospital services.

In recent years we have perhaps been complacent about how trauma care has improved with a significant focus on the early phases of the disease. This editorial points out that there is still work to do in both understanding the pathophysiology of trauma and also in the search for new solutions and therapies that might reduce the number of late deaths.

vb

S

@EMManchester

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References

  1. 1.
    Brohi K, Gruen RL, Holcomb JB. Why are bleeding trauma patients still dying? Intensive Care Med. February 2019. doi:10.1007/s00134-019-05560-x
  2. 2.
    Rehn M, Weaver A, Brohi K, et al. Effect of Pre-Hospital Red Blood Cell Transfusion on Mortality and Time of Death in Civilian Trauma Patients. SHOCK. April 2018:1. doi:10.1097/shk.0000000000001166
  3. 3.
    Lyon RM, de Sausmarez E, et al. Pre-hospital transfusion of packed red blood cells in 147 patients from a UK helicopter emergency medical service. Scand J Trauma Resusc Emerg Med. 2017;25(1). doi:10.1186/s13049-017-0356-2
  4. 4.
    Griggs JE, Jeyanathan J, et al. Mortality of civilian patients with suspected traumatic haemorrhage receiving pre-hospital transfusion of packed red blood cells compared to pre-hospital crystalloid. Scand J Trauma Resusc Emerg Med. 2018;26(1). doi:10.1186/s13049-018-0567-1
  5. 5.
    Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. The Lancet. 2010;376(9734):23-32. doi:10.1016/s0140-6736(10)60835-5
  6. 6.
    Grayson A. Trauma in the UK, who cares? St Emlyn’s • St Emlyn’s. St.Emlyn’s. https://www.stemlynsblog.org/trauma-in-the-uk-who-cares-st-emlyns/. Published December 31, 2018. Accessed February 13, 2019.
  7. 7.
    Moran CG, Lecky F, Bouamra O, et al. Changing the System – Major Trauma Patients and Their Outcomes in the NHS (England) 2008–17. EClinicalMedicine. 2018;2-3:13-21. doi:10.1016/j.eclinm.2018.07.001
  8. 8.
    Marsden M, Carden R, Navaratne L, et al. Outcomes following trauma laparotomy for hypotensive trauma patients. Journal of Trauma and Acute Care Surgery. May 2018:1. doi:10.1097/ta.0000000000001988
  9. 9.
    Harvin JA, Maxim T, Inaba K, et al. Mortality after emergent trauma laparotomy. Journal of Trauma and Acute Care Surgery. 2017;83(3):464-468. doi:10.1097/ta.0000000000001619
  10. 10.
    Carden R. What’s the bleeding problem with trauma laparotomies?! • St Emlyn’s. St.Emlyn’s. https://www.stemlynsblog.org/whats-the-bleeding-problem-with-trauma-laparotomies/. Published December 28, 2018. Accessed February 13, 2019.
  11. 11.
    Mira JC, Brakenridge SC, Moldawer LL, Moore FA. Persistent Inflammation, Immunosuppression and Catabolism Syndrome. Critical Care Clinics. 2017;33(2):245-258. doi:10.1016/j.ccc.2016.12.001
  12. 12.
    Efron PA, Mohr AM, Bihorac A, et al. Persistent inflammation, immunosuppression, and catabolism and the development of chronic critical illness after surgery. Surgery. 2018;164(2):178-184. doi:10.1016/j.surg.2018.04.011
  13. 13.
    TARN – Main Hospital Details. Trauma Audit and Research Network. https://www.tarn.ac.uk/Content.aspx?ca15&c=2897&hid=8003&pcid=3056. Published February 13, 2009. Accessed February 13, 2019.

Posted by Simon Carley

Professor Simon Carley MB ChB, PGDip, DipIMC (RCS Ed), FRCS (Ed)(1998), FHEA, FAcadMed, FRCEM, MPhil, MD, PhD is Creator, Webmaster, owner and Editor in Chief of the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. He is co-founder of BestBets, St.Emlyns and the MSc in emergency medicine at Manchester Metropolitan University. He is an Education Associate with the General Medical Council and is an Associate Editor for the Emergency Medicine Journal. His research interests include diagnostics, MedEd, Major incidents & Evidence based Emergency Medicine. He is verified on twitter as @EMManchester

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