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Treatment innovations save lives in traumatic injuries with severe bleeding

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UK deaths from severe bleeding after major trauma have been reduced by 40% over the past decade through a programme of research and innovation led by Queen Mary University of London, Barts Health NHS Trust and NHS Blood and Transplant.

Researchers examined the outcomes of 1,169 critically bleeding trauma patients who were managed with a ‘major haemorrhage protocol’ at the Royal London Hospital Major Trauma Centre between 2008 and 2017. This “Code Red” protocol was developed over time and involved new approaches to diagnosis and treatment of trauma-induced problems with blood clotting. These were introduced as a result of research conducted by the Centre for Trauma Sciences at Queen Mary and its partners.

Injuries that cause critical bleeding include those that are due to knife violence. The profile of trauma services has increased in recent years due to a surge in knife attacks in the capital. Official figures show there were 15.023 such offences in the year to June 2019, of which 63 were fatal.

In 2008, 48% of critically bleeding trauma patients died in hospital, a proportion reduced to 27% by 2017. These survivors were also more likely to be discharged to their homes, rather than to other facilities (57% of survivors in 2008 rising to 73% in 2017).

During this time a trauma research team worked alongside the clinical trauma team 24 hours a day, seven days a week. This joint working led to dramatic changes in resuscitation practice. Trauma teams stopped giving clear fluid infusions to patients while they were bleeding, instead using only red blood cell transfusions and clotting components derived from blood (such as plasma, platelets and cryoprecipitate transfusions). This included delivering blood to patients even before they reached hospital.

New devices to diagnose clotting problems at the patient bedside were introduced, allowing patient care to be individualised in real time. The clinical teams also introduced many human factor changes to smooth the delivery of life saving therapies and operation.

With all these changes, patients’ clotting problems could be managed and bleeding could be controlled. The overall number of red blood cell transfusions required by each patient fell significantly over the decade, from an average of 12 units in the first 24 hours in 2008, to only four units in 2017. The number of patients who required a “massive” transfusion (10 or more units of red blood cell transfusions – essentially replacing their entire blood volume) fell by more than half, from 68% in 2008 to 33% in 2017.

Dr Elaine Cole, from Queen Mary University of London, the study’s lead author said: “Changes in transfusion and resuscitation practice for traumatically injured patients that are rooted in research have led to remarkable improvements in survival. Close collaboration between clinical, transfusion and research teams enabled incremental adaptation of the Code Red protocol over time, rapidly implementing new research findings into clinical care.”

Co-author Professor Karim Brohi, consultant trauma surgeon at Barts Health NHS Trust, professor of trauma sciences at Queen Mary University of London and director of the London Trauma System, said: “Over ten years clinical and research trauma teams have worked hand-in-hand to understand what happens in the first few minutes after injury and how we can stop patients bleeding to death. We have reduced deaths by nearly a half, which is an incredible achievement in such a short period of time. There are still many opportunities to improve survival and this study also shows us where we need to focus our attention for the future.”

NHS Blood and Transplant medical and research director Gail Miflin said: “This work demonstrates the central role of blood transfusion resuscitation in the management of patients with major bleeding in trauma. The established partnership between NHSBT, Queen Mary University of London and Barts Health Trust has resulted in the integration of research into everyday transfusion practice of bleeding in trauma. This has improved the overall survival of patients over the last decade. We are delighted to be part of this work and look forward to working more closely with our clinical and academic partners at Barts Health Trust and Queen Mary to further improve outcomes of patients.”

Research projects leading to these changes were funded by several bodies including Barts Charity, the National Institute for Health Research, and the European Commission.

Abstract
Objective: The aim of this study was to identify the effects of recent innovations in trauma major hemorrhage management on outcome and transfusion practice, and to determine the contemporary timings and patterns of death.
Background: The last 10 years have seen a research-led change in hemorrhage management to damage control resuscitation (DCR), focused on the prevention and treatment of trauma-induced coagulopathy.
Methods: A 10-year retrospective analysis of prospectively collected data of trauma patients who activated the Major Trauma Centre’s major hemorrhage protocol (MHP) and received at least 1 unit of red blood cell transfusions (RBC).

Results: A total of 1169 trauma patients activated the MHP and received at least 1 unit of RBC, with similar injury and admission physiology characteristics over the decade. Overall mortality declined from 45% in 2008 to 27% in 2017, whereas median RBC transfusion rates dropped from 12 to 4 units (massive transfusion rates from 68% to 24%). The proportion of deaths within 24 hours halved (33%–16%), principally with a fall in mortality between 3 and 24 hours (30%–6%). Survivors are now more likely to be discharged to their own home (57%–73%). Exsanguination is still the principal cause of early deaths, and the mortality associated with massive transfusion remains high (48%). Late deaths are now split between those due to traumatic brain injury (52%) and multiple organ dysfunction (45%).
Conclusions: There have been remarkable reductions in mortality after major trauma hemorrhage in recent years. Mortality rates continue to be high and there remain important opportunities for further improvements in these patients.

Authors
Elaine Cole, Anne Weaver, Lewis Gall, Anita West, Daniel Nevin, Rosel Tallach, Breda O’Neill, Sumitra Lahiri, Shubha Allard, Nigel Tai, Ross Davenport, Laura Green, Karim Brohi

Queen Mary University of London material

Annals of Surgery abstract

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