Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization.
BACKGROUND
The importance of early and aggressive management of trauma- related coagulopathy remains poorly understood. We hypothesized that a trauma exsanguination protocol (TEP) that systematically provides specified numbers and types of blood components immediately upon initiation of resuscitation would improve survival and reduce overall blood product consumption among the most severely injured patients.


METHODS
We recently implemented a TEP, which involves the immediate and continued release of blood products from the blood bank in a predefined ratio of 10 units of packed red blood cells (PRBC) to 4 units of fresh frozen plasma to 2 units of platelets. All TEP activations from February 1, 2006 to July 31, 2007 were retrospectively evaluated. A comparison cohort (pre-TEP) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. Multivariable analysis was performed to compare mortality and overall blood product consumption between the two groups.


RESULTS
Two hundred eleven patients met inclusion criteria (117 pre-TEP, 94 TEP). Age, sex, and Injury Severity Score were similar between the groups, whereas physiologic severity (by weighted Revised Trauma Score) and predicted survival (by trauma-related Injury Severity Score, TRISS) were worse in the TEP group (p values of 0.037 and 0.028, respectively). After controlling for age, sex, mechanism of injury, TRISS and 24-hour blood product usage, there was a 74% reduction in the odds of mortality among patients in the TEP group (p = 0.001). Overall blood product consumption adjusted for age, sex, mechanism of injury, and TRISS was also significantly reduced in the TEP group (p = 0.015).


CONCLUSIONS
We have demonstrated that an exsanguination protocol, delivered in an aggressive and predefined manner, significantly reduces the odds of mortality as well as overall blood product consumption.
Cotton
Bryan A
BA
Departments of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA. bryan.cotton@vanderbilt.edu
Gunter
Oliver L
OL
Isbell
James
J
Au
Brigham K
BK
Robertson
Amy M
AM
Morris
John A
JA
St Jacques
Paul
P
Young
Pampee P
PP
D000328:Adult; D001778:Blood Coagulation Disorders / Q000209:etiology / Q000628:therapy*; D016913:Blood Component Transfusion / Q000706:statistics & numerical data*; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000628:therapy*; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D008297:Male; D010952:Plasma Substitutes / Q000627:therapeutic use*; D012042:Registries; D012189:Retrospective Studies; D016019:Survival Analysis; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014947:Wounds and Injuries / Q000145:classification / Q000150:complications* / Q000628:therapy
D010952:Plasma Substitutes