Factors affecting physicians' decision to start prehospital blood product transfusion in blunt trauma patients: A cohort study of Helsinki Trauma Registry.

BACKGROUND: Prehospital blood transfusions are increasing as a treatment for bleeding trauma patients at risk for exsanguination. Triggers for starting transfusion in the field are less studied. We analyzed the factors affecting the decision of physicians to start prehospital blood product transfusion (PHBT) in blunt adult trauma patients. STUDY DESIGN AND METHODS: Data of all adult blunt trauma patients from the Helsinki Trauma Registry between March 2016 and July 2021 were retrospectively analyzed. Univariate analysis for the identification of predictive factors and multivariate regression analysis for their importance as predictive factors for the initiation of PHBT were applied. RESULTS: There were 1652 patients registered in the database. A total of 556 of them were treated by a physician-level prehospital emergency care unit, of which by transfusion-capable unit in 394 patients. PHBT (red blood cells and/or plasma) was started in 19.8% of the patients. We identified three statistically highly important clinical triggers for starting PHBT: high crystalloid volume need, shock index ≥0.9, and need for prehospital pleural decompression. DISCUSSION: PHBT in blunt adult trauma patients is initiated in ~20% of the patients in Southern Finland. High crystalloid volume need, shock index ≥0.9 and prehospital pleural decompression are associated with the initiation of PHBT, probably reflecting patients at high risk for bleeding.

Deploying whole blood to the battlefield-The Israel Defense Forces Medical Corps initial experience during the 2023 war.

BACKGROUND: Military and prehospital medical organizations invest significant resources to advance the treatment of trauma patients aiming to reduce preventable deaths. Focus is on hemorrhage control and volume resuscitation with blood products, with adoption of Remote Damage Control Resuscitation (RDCR) guidelines. The Israel Defense Forces Medical Corps (IDF-MC) has been using tranexamic acid and freeze-dried plasma (FDP) as part of its RDCR protocol for more than a decade. In recent years, low-titer group O whole blood (LTOWB) has been integrated, on IDF evacuation helicopters and expanded to mobile ambulances, complementing FDP use in treating trauma patients in state of profound shock. STUDY DESIGN AND METHODS: During the war that erupted in October 2023, the IDF-MC made a decision to bring LTOWB forward, and to equip every combat brigade level mobile intensive care units with LTOWB, onboard armored vehicles. The goal was to make whole blood available as close as possible to the point of injury and within minutes from time of injury. RESULTS AND DISCUSSION: We describe the IDF-MCs' efforts to bring LTOWB to the front lines and present four cases in which LTOWB was administered. All patients were young male, with significant blood loss following penetrating injuries. One patient died in the operating room, following hospital arrival and emergency thoracotomy. The others survived. Our initial experience with bringing LTOWB as close as possible to the point of injury during high intensity fighting is encouraging, showing patient benefit along with logistic feasibility. After action reports and data collection will continue.

Initial experiences of prehospital blood product transfusions between 2016 and 2020 in Päijät-Häme hospital district, Finland.

BACKGROUND: Treating hemorrhaging patients with prehospital blood product transfusions (PHBT) narrows transfusion delays and potentially benefits the patient. We describe our initial experiences of PHBT in a ground-based emergency medical service (EMS), where the transfusion protocol covers both traumatic and nontraumatic hemorrhaging patients. METHODS: A descriptive retrospective analysis was performed on the records of all the patients receiving red blood cells, freeze-dried plasma, or both during prehospital care from September 2016 to December 2020. The delays of PHBT and the effects on patients' vital signs were analyzed and reported as the median and interquartile range (IQR) and analyzed using a Wilcoxon Signed rank test. RESULTS: 65 patients received prehospital blood product transfusions (PHBT), 29 (45%) were non-traumatic, and 36 (55%) traumatic. The main two reasons for PHBT were blunt trauma (n = 30, 46%) and gastrointestinal hemorrhage (n = 20, 31%). The median time from the emergency call to the start of PHBT was 54 min (IQR 38), and the transfusion began on a median of 61 min (IQR 42) before arrival at the hospital. The median systolic blood pressure improved from a median 76.5 mmHg (IQR 36.5) before transfusion to a median of 116.60 mmHg (IQR 26.5) (p < 0.001) on arrival to the hospital. No transfusion-related severe adverse events were noted. CONCLUSIONS: Starting PHBT in ground-based EMS is a feasible and viable option. The PHBT began significantly earlier than it would have started on arrival to the hospital, and it seems to be safe and improve patients' physiology. STUDY APPROVAL: D/2603/07.01.04.05/2019.

Brain Trauma, Glucocorticoids and Neuroinflammation: Dangerous Liaisons for the Hippocampus.

Glucocorticoid-dependent mechanisms of inflammation-mediated distant hippocampal damage are discussed with a focus on the consequences of traumatic brain injury. The effects of glucocorticoids on specific neuronal populations in the hippocampus depend on their concentration, duration of exposure and cell type. Previous stress and elevated level of glucocorticoids prior to pro-inflammatory impact, as well as long-term though moderate elevation of glucocorticoids, may inflate pro-inflammatory effects. Glucocorticoid-mediated long-lasting neuronal circuit changes in the hippocampus after brain trauma are involved in late post-traumatic pathology development, such as epilepsy, depression and cognitive impairment. Complex and diverse actions of the hypothalamic-pituitary-adrenal axis on neuroinflammation may be essential for late post-traumatic pathology. These mechanisms are applicable to remote hippocampal damage occurring after other types of focal brain damage (stroke, epilepsy) or central nervous system diseases without obvious focal injury. Thus, the liaisons of excessive glucocorticoids/dysfunctional hypothalamic-pituitary-adrenal axis with neuroinflammation, dangerous to the hippocampus, may be crucial to distant hippocampal damage in many brain diseases. Taking into account that the hippocampus controls both the cognitive functions and the emotional state, further research on potential links between glucocorticoid signaling and inflammatory processes in the brain and respective mechanisms is vital.

Fresh Low Titer O Whole Blood Transfusion in the Austere Medical Environment.

Massive hemorrhage is an immediate threat to life. The military developed the Tactical Combat Casualty Care guidelines to address the management of acute trauma, including administration of blood products. The guidelines have been expanded to include low titer O whole blood, which is in limited use by the military. This proposal describes how the transfusion of fresh whole blood might be applied to the remote civilian environment. In doing so, this life-saving intervention may be brought to the austere medical environment, allowing critically hemorrhaging patients to survive to reach definitive medical care.

Plasticity of microglia in remote regions after focal brain injury.

The CNS is endowed with an intrinsic ability to recover from and adapt secondary compensatory mechanisms to injury. The basis of recovery stems from brain plasticity, defined as the brain's ability to make adaptive changes on structural and functional levels, ranging from molecular, synaptic, and cellular changes in response to alterations in their environment. In this multitude of responses, microglia have an active role and contribute to brain plasticity through their dynamic responses. This review will provide an overview of microglial responses in the context of acute CNS injury and their function in post-traumatic repair and assess the changes that are induced by damage in remote areas from, but functionally connected to, the primary site of injury. In the second section, we highlight the effects of several therapeutic approaches, with particular interest paid to specialized pro-resolving lipid mediators, in modulating microglial responses in remote regions and enhancing long-term functional recovery via suppression of neurodegenerative cascades that are induced by damage, which may contribute to a translational bridge from bench to bedside.

Damage control: Concept and implementation.

The concept of damage control (DC) is based on a sequential therapeutic strategy that favors physiological restoration over anatomical repair in patients presenting acutely with hemorrhagic trauma. Initially described as damage control surgery (DCS) for war-wounded patients with abdominal penetrating hemorrhagic trauma, this concept is articulated in three steps: surgical control of lesions (hemostasis, sealing of intestinal spillage), physiological restoration, then surgery for definitive repair. This concept was quickly adapted for intensive care management under the name damage control resuscitation (DCR), which refers to the modalities of hospital resuscitation carried out in patients suffering from traumatic hemorrhagic shock within the context of DCS. It is based mainly on specific hemodynamic resuscitation targets associated with early and aggressive hemostasis aimed at prevention or correction of the lethal triad of hypothermia, acidosis and coagulation disorders. Concomitant integration of resuscitation and surgery from the moment of admission has led to the concept of an integrated DCR-DCS approach, which enables initiation of hemostatic resuscitation upon arrival of the injured person, improving the patient's physiological status during surgery without delaying surgery. This concept of DC is constantly evolving; it stresses management of the injured person as early as possible, in order to initiate hemorrhage control and hemostatic resuscitation as soon as possible, evolving into a concept of remote DCR (RDCR), and also extended to diagnostic and therapeutic radiological management under the name of radiological DC (DCRad). DCS is applied only to the most seriously traumatized patients, or in situations of massive influx of injured persons, as its universal application could lead to a significant and unnecessary excess-morbidity to injured patients who could and should undergo definitive treatment from the outset. DCS, when correctly applied, significantly improves the survival rate of war-wounded.

Remote Damage Control Resuscitation in Austere Environments.

Hemorrhage is the leading cause of preventable military and civilian trauma death. Damage control resuscitation with concomitant mechanical hemorrhage control has become the preferred in-hospital treatment of hemorrhagic shock. In particular, plasma-based resuscitation with decreased volumes of crystalloids and artificial colloids as part of damage control resuscitation has improved outcomes in the military and civilian sectors. However, translation of these principles and techniques to the prehospital, remote, and austere environments, known as remote damage control resuscitation, is challenging given the resource limitations in these settings. Rapid administration of tranexamic acid and reconstituted freeze-dried (lyophilized) plasma as early as the point of injury are feasible and likely beneficial, but comparative studies in the literature are lacking. Whole blood is likely the best fluid therapy for traumatic hemorrhagic shock, but logistical hurdles need to be addressed. Rapid control of external hemorrhage with hemostatic dressings and extremity tourniquets are proven therapies, but control of noncompressible hemorrhage (ie, torso hemorrhage) remains a significant challenge.

Autophagy Inhibition Favors Survival of Rubrospinal Neurons After Spinal Cord Hemisection.

Spinal cord injuries (SCIs) are devastating conditions of the central nervous system (CNS) for which there are no restorative therapies. Neuronal death at the primary lesion site and in remote regions that are functionally connected to it is one of the major contributors to neurological deficits following SCI.Disruption of autophagic flux induces neuronal death in many CNS injuries, but its mechanism and relationship with remote cell death after SCI are unknown. We examined the function and effects of the modulation of autophagy on the fate of axotomized rubrospinal neurons in a rat model of spinal cord dorsal hemisection (SCH) at the cervical level. Following SCH, we observed an accumulation of LC3-positive autophagosomes (APs) in the axotomized neurons 1 and 5 days after injury. Furthermore, this accumulation was not attributed to greater initiation of autophagy but was caused by a decrease in AP clearance, as demonstrated by the build-up of p62, a widely used marker of the induction of autophagy. In axotomized rubrospinal neurons, the disruption of autophagic flux correlated strongly with remote neuronal death and worse functional recovery. Inhibition of AP biogenesis by 3-methyladenine (3-MA) significantly attenuated remote degeneration and improved spontaneous functional recovery, consistent with the detrimental effects of autophagy in remote damage after SCH. Collectively, our results demonstrate that autophagic flux is blocked in axotomized neurons on SCI and that the inhibition of AP formation improves their survival. Thus, autophagy is a promising target for the development of therapeutic interventions in the treatment of SCIs.

Clinical Observation of Xingnaojing Injection Combined with Butylphthalide in the Treatment of Middle Cerebral Artery Infarction / 中国药房

OBJECTIVE:To investigate the effects and safety of Xingnaojing injection combined with butylphthalide on neuro-logical function,cognitive function,coagulation function and living activity. METHODS:A total of 106 patients with middle cere-bral artery infarction in Wuhan University People's Hospital during Jun. 2014-Dec. 2015 were divided into control group and obser-vation group according to random number table,with 53 cases in each group. Besides routine symptomatic treatment,control group was given Butylphthalide soft capsules 0.2 g,po,tid. Observation group was additionally given Xingnaojing injection 20 mL added into 0.9% Sodium chloride injection 250 mL,ivgtt,qd. Both groups were treated for 14 d. The neurological function score (NI-HSS,NFDS),cognitive function score (MoCA,MMSE),coagulation function indexes (PT,APTT,FIB),BI score were ob-served in 2 groups before and after treatment. The occurrence of secondary remote damage and ADR were recorded. RESULTS:Eight patients withdrew from the study,including 3 patients of control group and 5 of observation group. Before treatment,there was no statistical significance in neurological function scores(NIHSS,NFDS),cognitive function scores(MoCA,MMSE),coag-ulation function indexes or BI scores between 2 groups (P>0.05). After treatment,NIHSS,NFDS scores and FIB of 2 groups were decreased significantly compared to before treatment,and the observation group was significantly lower than the control group,with statistical significance (P0.05). CONCLUSIONS:For middle cerebral artery infarction,the application of Xingnaojing injection combined with butylphthalide can reduce the risk of remote damage,promote the recovery of neurological function and cognitive func-tion,and improve coagulation function and living activity with good safety.

Effects of electric acupuncture on amount of cerebral cortex and spinal neuron in hypertensive rats after cerebral infarction / 中国中西医结合急救杂志

Objective To observe the effect of electric acupuncture on the infarct volume and amount of cerebral cortex and spinal neuron at different times of cerebral ischemia/reperfusion(I/R)in stroke prone renovascular hypertensive rats(RHRSP)with middle cerebral artery occlusion(MCAO),and investigate the possible mechanisms of electric acupuncture on remote damage in ischemic stroke. Methods 480 male SPF Sprague-Dawley(SD)rats were duplicated to form the RHRSP models by clamping both kidneys. 370 successful ones were selected by taking the tail artery blood pressure,and divided into hypertension group and sham operation group(each n=60)by random number table method. The MCAO models were created by stringing middle cerebral artery in the remaining RHRSP. The nerve function defect score(NDS)was graded by Longa 5 point method after the rats waked up from anesthesia,then the ones scored 1-3 were enrolled. Totally,there were 190 rats with MCAO successfully created from which 10 were randomly selected to determine the infarct size by 2,3,5-triphenyl four azole nitrogen chloride(TTC)staining. The remaining 180 MCAO rats were randomly divided into model group,electric acupuncture group and fake acupuncture group(each n=60). The sham operated group only received surgical trauma;the electrical acupunctures atBaihuiandDazhuiacupoints on Du channel were performed on the day of model establishment in electric acupuncture group,once a day for 28 days;in fake acupuncture group,sticked the acupuncture needles at the skin ofBaihuiandDazhuipoints,then gived the same electrical acupuncture treatment. On 1,7,14 and 28 days after treatment,the rats of each group were respectively sacrificed,and the brains were collected,then the infarct volume and spinal neuron number were calculated by Nissl staining. Results ①Cerebral infarction volume:No infarcts were found in hypertension group and sham operated group. On 1 day and 7 days after MCAO,the infarct volumes were increased gradually in model group,electric acupuncture group and fake acupuncture group〔infarct volumes on 1 day were(12.36±0.11)%, (12.19±0.15)%,(12.24±0.16)%,and on 7 days were(20.01±0.24)%,(19.54±0.61)%and(19.77±0.25)%, respectively〕,and on 14 days and 28 days after MCAO,the infarct volumes were decreased gradually〔infarct volumes on 14 days were(17.18±0.23)%,(16.96±0.11)%,(17.08±0.62)%,and on 28 days were(14.38±0.21)%, (13.95±0.46)% and(14.29±0.37)%,respectively〕,but the differences among three groups had no statistical significance(all P>0.05). ② Cortex area:On 1 day after MCAO,the differences in the cortical neuron numbers among all groups were not statistically significant(all P>0.05). On 7,14,28 days after MCAO,the cortical neuron number of sham operated group was more than that of hypertension group,but the difference had no statistical significance(all P>0.05). Compared with sham operated group,the cortical neuron number in model group began to increase significantly after 7 days;compared with model group,the cortical neuron number in electric acupuncture group was increased obviously(cell/HP,7 days:75.48±2.41 vs. 68.78±1.42,14 days:61.32±2.60 vs. 48.78±1.41,28 days:53.65±1.46 vs. 28.78±1.21,all P0.05).③Spinal cord area:On 1,7,14 days after MCAO, the differences of the spinal cord neuron numbers among all groups were not statistically significant(all P>0.05). On 28 days,compared with hypertension group,the cord neuron number of sham operated group was increased,but the difference had no statistical significance(P>0.05). Compared with model group,the cord neuron number in electric acupuncture and fake acupuncture groups was inecreased(cell/HP:21.32±1.60,16.17±1.05 vs. 15.02±1.18),the difference being statistical significant in electric acupuncture group(P0.05). Conclusions Generally,the secondary spinal(cervical part)neuron death occurs after cerebral infarction in rats. The therapeutic action of electric acupuncture may reduce the secondary spinal neuron damage at remote site after cerebral infarction,that is possibly the mechanism of electric acupuncture for the protection of brain in hypertensive rats from I/R injury.