Breaking barriers in trauma research: A narrative review of opportunities to leverage veterinary trauma for accelerated translation to clinical solutions for pets and people.

Trauma is a common cause of morbidity and mortality in humans and companion animals. Recent efforts in procedural development, training, quality systems, data collection, and research have positively impacted patient outcomes; however, significant unmet need still exists. Coordinated efforts by collaborative, translational, multidisciplinary teams to advance trauma care and improve outcomes have the potential to benefit both human and veterinary patient populations. Strategic use of veterinary clinical trials informed by expertise along the research spectrum (i.e., benchtop discovery, applied science and engineering, large laboratory animal models, clinical veterinary studies, and human randomized trials) can lead to increased therapeutic options for animals while accelerating and enhancing translation by providing early data to reduce the cost and the risk of failed human clinical trials. Active topics of collaboration across the translational continuum include advancements in resuscitation (including austere environments), acute traumatic coagulopathy, trauma-induced coagulopathy, traumatic brain injury, systems biology, and trauma immunology. Mechanisms to improve funding and support innovative team science approaches to current problems in trauma care can accelerate needed, sustainable, and impactful progress in the field. This review article summarizes our current understanding of veterinary and human trauma, thereby identifying knowledge gaps and opportunities for collaborative, translational research to improve multispecies outcomes. This translational trauma group of MDs, PhDs, and DVMs posit that a common understanding of injury patterns and resulting cellular dysregulation in humans and companion animals has the potential to accelerate translation of research findings into clinical solutions.

Stop the Bleed in the Era of Virtual Learning: A Novel Strategy for Remote Teaching and Evaluation.

INTRODUCTION: Traumatic hemorrhage is a leading cause of preventable mortality worldwide. The Stop the Bleed (STB) course was developed to equip layperson bystanders with basic bleeding control knowledge and skills. However, large in-person courses have been disrupted due to COVID-19. The aim of this study was to determine the feasibility of teaching and evaluating STB skills through remote video-based instruction. METHODS: After undergoing COVID-19 screening, groups of up to eight STB-naive adults were seated in a socially distanced manner and given individual practice kits. A remote STB-certified instructor provided the standard STB lecture and led a 10-min skills practice session via videoconferencing. Participants' skills were evaluated on a 10-point rubric by one in-person evaluator and three remote evaluators. Participants completed a postcourse survey assessing their perceptions of the course. RESULTS: Thirty-five participants completed the course, all scoring ≥8/10 after examination by the in-person evaluator. Remote instructors' average scores (9.8 ± 0.45) did not significantly differ from scores of the in-person evaluator (9.9 ± 0.37) (P = 0.252). Thirty-three participants (94%) completed the postcourse survey. All respondents reported being willing and prepared to intervene in scenarios of life-threatening hemorrhage, and 97% reported confidence in using all STB skills. CONCLUSIONS: STB skills can be effectively taught and evaluated through a live video-based course. All participants scored highly when evaluated both in-person and remotely, and nearly all reported confidence in skills and knowledge following the course. Remote instruction is a valuable strategy to disseminate STB training to students without access to in-person courses, especially during pandemic restrictions.

Pre-hospital tranexamic acid administration in patients with a severe hemorrhage: an evaluation after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol.

PURPOSE: To evaluate the pre-hospital administration of tranexamic acid in ambulance-treated trauma patients with a severe hemorrhage after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol. METHODS: All patients with a severe hemorrhage who were treated and conveyed by EMS professionals between January 2015, and December 2017, to any trauma-receiving emergency department in the eight participating trauma regions in the Netherlands, were included. A severe hemorrhage was defined as extracranial injury with > 20% body volume blood loss, an extremity amputation above the wrist or ankle, or a grade ≥ 4 visceral organ injury. The main outcome was to determine the proportion of patients with a severe hemorrhage who received pre-hospital treatment with tranexamic acid. A Generalized Linear Model (GLM) was performed to investigate the relationship between pre-hospital tranexamic acid treatment and 24 h mortality. RESULTS: A total of 477 patients had a severe hemorrhage, of whom 124 patients (26.0%) received tranexamic acid before arriving at the hospital. More than half (58.4%) of the untreated patients were suspected of a severe hemorrhage by EMS professionals. Patients treated with tranexamic acid had a significantly lower risk on 24 h mortality than untreated patients (OR 0.43 [95% CI 0.19-0.97]). CONCLUSION: Approximately a quarter of the patients with a severe hemorrhage received tranexamic acid before arriving at the hospital, while a severe hemorrhage was suspected in more than half of the non-treated patients. Severely hemorrhaging patients treated with tranexamic acid before arrival at the hospital had a lower risk to die within 24 h after injury.

The predictive value of four traumatic hemorrhage scores for early massive blood transfusion in trauma patients in the pre-hospital setting.

OBJECTIVES: We aimed to explore the predictive value of four traumatic hemorrhage scores for early massive blood transfusion in trauma patients in the pre-hospital setting. METHODS: Trauma patients admitted to Shenzhen University General Hospital from July 2018 to December 2022 were included in this study. They were divided into the massive transfusion group and the non-massive transfusion group according to the blood transfusion volume within 24 h. Basic information about patients was collected. Glasgow Coma Scale (GCS), focused assessment with sonography for trauma (FAST), and injury severity score (ISS) were performed. The receiving operating characteristic (ROC) curve was used to compare the predictive value of four trauma transfusion scores for early massive blood transfusion in the pre-hospital setting. RESULTS: A total of 475 patients were enrolled, 43 received massive blood transfusions and 29 died within 24 h. The sensitivity and specificity of the four trauma hemorrhage scores in predicting the need for massive blood transfusions in trauma patients at their recommended cutoff points were all high. Among the four scores, the area under the ROC curve was larger for the assessment of blood consumption (ABC) score (0.864) and smaller for the trauma-induced coagulopathy clinical score (TICCS) score (0.795, p > 0.05). CONCLUSIONS: All four pre-hospital trauma hemorrhage scores have a high predictive value in assessing massive blood transfusion in trauma patients.

Delayed Traumatic Intracerebral Hematoma: A Pathophysiological Classification and Literature Review.

Delayed traumatic intracerebral hematoma (DTICH) is a relatively common occurrence after a traumatic brain injury (TBI). Several case series have been performed to study DTICH, many of which offer different definitions of DTICH. Some definitions involve a delayed progression of an existing hemorrhage, and others involve a de novo intracerebral hematoma that was not evident on the initial trauma evaluation. We propose a classification system for DTICH that accounts for the subtleties in the clinical manifestation and pathophysiology of the different types of DTICH, with the ultimate goal of providing strategies to prevent and manage DTICH. Based on the senior author's clinical experience, we generated a classification system for DTICH, and each type of DTICH was illustrated with a case. We defined type 1A (case 1A), the classic presentation of DTICH as predominantly characterized in the literature, as an intracerebral hematoma unseen on initial computed tomography imaging that typically develops five days to one week following blunt or penetrating head trauma. We defined type 1B (case 1B) as a hematoma that forms after at least one week following trauma in areas of the brain initially hemorrhage-free. We defined type 2 (case 2) as a hematoma that develops rapidly following a surgical evacuation of a different hematoma. We defined type 3 (case 3) as a hematoma that develops after a traumatic head injury in areas of non-hemorrhagic contusion, usually frontal or temporal. A literature review was performed using select terms on PubMed to find articles related to DTICH, excluding articles describing DTICH from an underlying vascular injury. After performing the literature review and screening articles by title and/or abstract, a total of 79 articles were found to meet the inclusion and exclusion criteria. We recorded which type of DTICH from our classification system best correlated with the articles in our literature review. Taken together with results from the literature, the proposed classification system is based on the senior author's clinical experience. Overall, DTICH is a relatively common occurrence after head trauma, and our pathophysiologic classification has the potential to help outline future studies to recognize and prevent the development of DTICH.

Traumatic hemorrhage and chain of survival.

Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.

Hypofibrinogenemic Massive Transfusion Trauma Patients Experience Worse Outcomes.

INTRODUCTION: Uncontrolled hemorrhage accounts for up to 40% of trauma-related mortality. Previous reports demonstrate that decreased fibrinogen levels during traumatic hemorrhage are associated with worse outcomes. Cryoprecipitate is used to replace fibrinogen for patients in hemorrhagic shock undergoing massive transfusion (MT), though the optimal ratio of cryoprecipitate to fresh frozen plasma (FFP), packed red blood cells (PRBCs), and platelets remains undefined. The purpose of this study is to investigate the effect of admission fibrinogen level and the use of cryoprecipitate on outcomes in trauma patients undergoing MT. METHODS: A prospective practice management guideline was established to obtain fibrinogen levels on adult trauma patients undergoing MT at a level I trauma center from December 2019 to December 2021. Ten units of cryoprecipitate were administered every other round of MT. Thromboelastography (TEG) was also obtained at the initiation and completion of MT. Patient demographic, injury, transfusion, and outcome data were collected. Hypofibrinogenemic (<200 mg/dL) patients at initiation of MT were compared to patients with a level of 200 mg/dL or greater. RESULTS: A total of 96 out of 130 patients met criteria and underwent MT with a median admission fibrinogen of 170.5 mg/dL. Hypofibrinogenemia was associated with elevated INR (1.26 vs 1.13, P < .001) and abnormal TEG including decreased alpha angle (68.1 vs 73.3, P < .001), increased K time (1.7 vs 1.1, P < .001), and decreased max amplitude (58 vs 66, P < .001). Patients with hypofibrinogenemia received more PRBC (10 vs 7 U, P = .002), FFP (9 vs 6 U, P = .003), and platelets (2 vs 1 U, P = .004) during MT. Hypofibrinogenemic patients demonstrated greater mortality than patients with normal levels (50% vs 23.5%, P = .021). Older age, decreased GCS, and elevated injury severity score (ISS) were risk factors for mortality. Increased fibrinogen was associated with lower odds of mortality (P = .001). Age, ISS, and fibrinogen level remained significantly associated with mortality in a multivariable analysis. Overall, fibrinogen in post-MT survivors showed an increase in median level compared to admission (231 vs 177.5 mg/dL, P < .001). CONCLUSION: Trauma patients undergoing MT with decreased admission fibrinogen demonstrate increased mortality. Other mortality risk factors include older age, decreased GCS, and higher ISS. Patients with increased fibrinogen levels had lower odds of mortality in a multivariable model. Post-MT survivors demonstrated significantly higher fibrinogen levels than pre-MT patients. Hypofibrinogenemic patients also had worse TEG parameters and required more PRBCs, FFP, and platelets during MT. Further studies are needed to assess the optimal volume of fibrinogen replacement with cryoprecipitate during MT to improve trauma patient mortality.

Local YB-1, Epo, and EpoR concentrations in fractured bones: results from a porcine model of multiple trauma.

Little is known about the impact of multiple trauma (MT)-related systemic hypoxia on osseous protein concentration of the hypoxia transcriptome. To shed light on this issue, we investigated erythropoietin (Epo), erythropoietin receptor (EpoR), and Y-box binding protein 1 (YB-1) concentrations in the fracture zone in a porcine MT + traumatic hemorrhage (TH) model. Sixteen male domestic pigs were randomized into two groups: an MT + TH group and a sham group. A tibia fracture, lung contusion, and TH were induced in the MT + TH group. The total observation period was 72 h. YB-1 concentrations in bone marrow (BM) were significantly lower in the fracture zone of the MT + TH animals than in the sham animals. Significant downregulation of BM-localized EpoR concentration in both unfractured and fractured bones was observed in the MT + TH animals relative to the sham animals. In BM, Epo concentrations were higher in the fracture zone of the MT + TH animals compared with that in the sham animals. Significantly higher Epo concentrations were detected in the BM of fractured bone compared to that in cortical bone. Our results provide the first evidence that MT + TH alters hypoxia-related protein concentrations. The impacts of both the fracture and concomitant injuries on protein concentrations need to be studied in more detail to shed light on the hypoxia transcriptome in fractured and healthy bones after MT + TH.

The Clinical Application of Machine Learning-Based Models for Early Prediction of Hemorrhage in Trauma Intensive Care Units.

Uncontrolled post-traumatic hemorrhage is an important cause of traumatic mortality that can be avoided. This study intends to use machine learning (ML) to build an algorithm based on data collected from an electronic health record (EHR) system to predict the risk of delayed bleeding in trauma patients in the ICU. We enrolled patients with torso trauma in the surgical ICU. Demographic features, clinical presentations, and laboratory data were collected from EHR. The algorithm was designed to predict hemoglobin dropping 6 h before it happened and evaluated the performance with 10-fold cross-validation. We collected 2218 cases from 2008 to 2018 in a trauma center. There were 1036 (46.7%) patients with positive hemorrhage events during their ICU stay. Two machine learning algorithms were used to predict ongoing hemorrhage events. The logistic model tree (LMT) and the random forest algorithm achieved an area under the curve (AUC) of 0.816 and 0.809, respectively. In this study, we presented the ML model using demographics, vital signs, and lab data, promising results in predicting delayed bleeding risk in torso trauma patients. Our study also showed the possibility of an early warning system alerting ICU staff that trauma patients need re-evaluation or further survey.

Life-threatening gastrointestinal bleeding from splenic artery pseudoaneurysm due to gastric ulcer penetration treated by surgical hemostasis with resuscitative endovascular balloon occlusion of the aorta: A case report.

We report the case of a patient for whom surgical hemostasis of gastrointestinal bleeding due to a splenic artery pseudoaneurysm, which developed due to gastric ulcer penetration, was achieved with resuscitative endovascular balloon occlusion of the aorta without ischemia of organs including the spleen.

Stop the Bleed in Rural Sierra Leone: One Year of Interventions and Outcomes by Nursing Trainees.

BACKGROUND: Low- and middle-income countries (LMICs) bear the bulk of the global burden of traumatic injury, yet many lack adequate prehospital trauma care systems. The Stop the Bleed (STB) course, designed to equip bystanders with bleeding control skills, is infrequently offered in LMICs, and its impact in these settings is unknown. To examine the frequency and effectiveness of STB interventions in LMICs, we quantified nursing student trainees' encounters with bleeding victims after STB training in rural Sierra Leone. METHODS: Local providers and volunteers from a US-based surgical nongovernmental organization taught an STB course to nursing students in Kabala, Sierra Leone. One month and 1 year after the course, trainees completed follow-up surveys describing encounters with traumatic hemorrhage victims since the course. RESULTS: Of 121 total STB trainees, 82 completed the 1-month follow-up survey, with 75% reporting at least one encounter with a bleeding victim. This increased to 98% at 12 months (100 responses, average 2 ± 2 encounters). Injuries were most commonly sustained on victims' legs (32%) and most often precipitated by motorcycle crashes (31%). Respondents intervened in 99% of encounters, and 97% of patients receiving intervention survived. Although only 20% of respondents used a tourniquet, this technique produced the highest survival rate (100%). CONCLUSIONS: Nearly all respondents had encounters with victims of traumatic hemorrhage within 1 year of the STB course, and trainees effectively applied bleeding control techniques, leading to 97% survival among victims receiving intervention. These findings indicate the lifesaving impact of STB training in one rural LMIC setting.

The Influence of Macrophage-Activating Lipopeptide-2 in Regard to Liver-Specific Changes Within a Murine Two-Hit Model.

Trauma hemorrhage (TH) and subsequent sepsis are well known to frequently result in severe organ damage. Although macrophage-activating lipopeptide-2 (MALP-2) has been described to exert beneficial effects on organ damage, and further clinical course after both isolated trauma and sepsis, little is known about the impact of MALP-2 in a clinically realistic two-hit scenario of TH and subsequent sepsis. As the liver represents a key organ for the posttraumatic immune response and development of complications, the effects of MALP-2 on the posttraumatic hepatic immunologic response and tissue damage were investigated in a murine "two-hit" model. In C57BL/6 mice, blood pressure-controlled (35 ± 5 mm Hg) TH was induced. Cecal ligation and puncture (CLP) was performed 48 h after TH. Mice were divided into two control groups (control 1, TH and laparotomy without CLP; control 2, TH and CLP) and three experimental groups (TH + CLP) treated with MALP-2 at different timepoints (ETH, end of TH; ECLP, end of CLP; 6CLP, 6 h after CLP). The observation time lasted for 168 h after induction of TH. Kupffer cells (KC) were isolated and cultured, and MPO activity was analyzed. Cell culture supernatants were taken for cytokine analysis (TNF-α, IL-6, MCP-1, GM-CSF, IL-10). Histological analysis was performed using the Hepatic Injury Severity Scoring (HISS). Statistical evaluation was carried out using SPSS (version 24.0.0; IBM, Armonk, NY, USA). MPO activity of control 1 group was lowest compared with all the other groups (p < 0.01). MPO activity of control 2 group was significantly higher than that in all experimental groups (ETH (p < 0.01), ECLP (p < 0.01), and 6CLP (p = 0.03)). Within the experimental groups, MPO activity was significantly reduced in the ETH (p = 0.04) and the ECLP (p < 0.01) groups compared with the 6CLP group. Moreover, ETH was also associated with the most pronounced reduction of cytokine expression by KC (p < 0.05). HISS revealed the largest damage in the group control 2. TH and subsequent sepsis lead to a distinct immunologic reaction in the liver with an increase of cytokine expression of KC and pronounced infiltration of granulocytes with associated severe tissue damage. MALP application decreases the hepatic immune response and liver damage, with the most pronounced effects if applied at the end of TH.

CT of acute abdominopelvic hemorrhage: protocols, pearls, and pitfalls.

Abdominal and pelvic hemorrhage may be secondary to a number of causes and is often a medical emergency. Patient presentation ranges from obvious trauma with evidence of hemodynamic instability to vague symptoms. CT has become the imaging modality of choice for identifying abdominopelvic hemorrhage. Recognizing acute hemorrhage as well as identifying its location and severity are key to expediting management. In the Emergency Department, ultrasound often used in the initial evaluation of trauma patients, but is not sensitive for subtle bleeds or injuries. CT is the best first-line imaging tool to identify abdominal hemorrhage and, compared with angiography, has been shown to be superior in detecting intra-abdominal bleeding, especially when the bleeding rate is low. Depending on location and etiology, abdominopelvic hemorrhage may have a characteristic appearance, such as the "sentinel clot" sign associated with blunt trauma to the solid organs or the "triangle sign" of a mesenteric bleed. The following pictorial essay reviews CT technique, study interpretation, and interpretative pearls and pitfalls in the recognition of acute abdominopelvic hemorrhage.

Tranexamic Acid Inhibits Hematoma Expansion in Intracerebral Hemorrhage and Traumatic Brain Injury. Does Blood Pressure Play a Potential Role? A Meta-Analysis from Randmized Controlled Trials.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic agent, which has shown an effect on reducing blood loss in many diseases. Many studies focus on the effect of TXA on cerebral hemorrhage, however, whether TXA can inhibit hematoma expansion is still controversial. Our meta-analysis performed a quantitative analysis to evaluate the efficacy of TXA for the hematoma expansion in spontaneous and traumatic intracranial hematoma. METHOD: Pubmed (MEDLINE), Embase, and Cochrane Library were searched from January 2001 to May 2020 for randomized controlled trials (RCTs). RESULT: We pooled 3102 patients from 7 RCTs to evaluate the efficacy of TXA for hematoma expansion. Hematoma expansion (HE) rate and hematoma volume (HV) change from baseline were used to analyze. We found that TXA led to a significant reduction in HE rate (P = 0.002) and HV change (P = 0.03) compared with the placebo. Patients with moderate or serious hypertension benefit more from TXA. (HE rate: P = 0.02, HV change: P = 0.04) TXA tends to have a better efficacy on HV change in intracerebral hemorrhage (ICH). (P = 0.06) CONCLUSIONS: TXA showed good efficacy for hematoma expansion in spontaneous and traumatic intracranial hemorrhage. Patients with moderate/severe hypertension and ICH may be more suitable for TXA administration in inhibiting hematoma expansion .

Effects of massive blood transfusion on inflammatory factors, islet B cell function, MODS incidence and mortality in patients with severe traumatic hemorrhage / 中国输血杂志

【Objective】 To explore the effect of massive blood transfusion on inflammatory factors, islet B cell function, incidence and mortality of multiple organ dysfunction syndrome (MODS) in patients with severe traumatic hemorrhage. 【Methods】 214 traumatic hemorrhage patients who received blood transfusion and were hospitalized in the Third People′s Hospital of Xingtai from January 2015 to June 2019 were enrolled and divided into the routine blood transfusion group (n=118) and massive blood transfusion group (n=96) according to the amount and method of blood transfusion. The changes of the inflammatory factors such as TNF α and IL-6, the functional indexes of Islet B cells such as HOMA-B and Δ INS30 / Δ GLU30, and the incidence and mortality of MODS in two groups 3 d after blood transfusion were observed. 【Results】 The level of TNF α(ng/L), IL-6(ng/L), HOMA-B and Δ INS30 / Δ GLU30 were (64.21±8.41) vs (30.75±5.26), (216.52±17.99) vs (152.45±16.26) (58.55±10.23) vs (103.47±17.48) and (2.95±0.69) vs (5.87±1.30) in the massive transfusion group and routine transfusion group, respectively (P<0.01). The incidence of MODS was 63.54%(61/96) vs 40.07%(52/118)(P<0.01) while the mortality of MODS was 46.88%(40/118) vs 33.90% (P>0.05). 【Conclusion】 The massive blood transfusion could increase the incidence of MODS in patients with severe traumatic hemorrhage by promoting inflammatory reaction and dysfunction of islet B cells.

Trauma CT evaluation prior to selective angiography in patients with traumatic injuries: negative predictive power and factors affecting its utility.

PURPOSE: To evaluate the predictive power of arterial injury detected on contrast-enhanced CT (trauma CT (tCT)) imaging obtained prior to selective angiography for treatment of patients with traumatic abdominal and pelvic injuries. MATERIALS AND METHODS: A retrospective chart review was performed of all patients who underwent angiography after undergoing contrast-enhanced CT imaging for the evaluation/treatment of traumatic injuries to the abdomen and pelvis between March 2014 and September 2018. Data collection included demographics, pertinent history and physical findings, CT and angiography findings, treatment information, and outcomes. RESULTS: Eighty-nine (63 males, mean age = 45.8 ± 20.5 years) patients that were found to have 102 traumatic injuries on tCT and subsequently underwent angiography met inclusion criteria for this study. Sixty-four injuries demonstrated evidence of traumatic vascular injury on initial tCT. A negative tCT was able to predict subsequent negative angiography in 83% of cases (negative predictive power = 83%). The ability of tCT to rule out a positive finding on subsequent angiography was also 83% (sensitivity = 83%). The average systolic blood pressure and hemoglobin concentration at the time of tCT were higher in patients who had positive tCT than in patients with negative tCT (p < 0.05 and p < 0.01, respectively). The average time to angiography was greater in patients whom had subsequent negative angiography than the patients who had subsequent positive angiography (p < 0.05). CONCLUSION: Contrast-enhanced CT imaging may be able to help stratify patients who may have subsequent negative angiograms. Hemodynamic factors may affect sensitivity of tCT. Shorter time to angiography may increase the chance of identifying the injury on subsequent angiography.

World trauma education: hemorrhage control training for healthcare providers in India.

BACKGROUND: Hemorrhage remains a major cause of death around the world. Eighty percent of trauma patients in India do not receive medical care within the first hour. The etiology of these poor outcomes is multifactorial. We describe findings from the first Stop the Bleed (StB) course recently offered to a group of medical providers in southern India. METHODS: A cross-sectional survey of 101 participants who attended StB trainings in India was performed. Pre-training and post-training questionnaires were collected from each participant. In total, 88 healthcare providers' responses were analyzed. Three bleeding control skills were presented: wound compression, wound packing, and tourniquet application. RESULTS: Among participants, only 23.9% had received prior bleeding control training. Participants who reported feeling 'extremely confident' responding to an emergency medical situation rose from 68.2% prior to StB training to 94.3% post-training. Regarding hemorrhage control abilities, 37.5% felt extremely confident before the training, compared with 95.5% after the training. For wound packing and tourniquet application, 44.3% and 53.4%, respectively, felt extremely confident pre-training, followed by 97.7% for both skills post-training. Importantly, 90.9% of StB trainees felt comfortable teaching newly acquired hemorrhage control skills. A significant majority of participants said that confidence in their wound packing and tourniquet skills would improve with more realistic mannequins. CONCLUSION: To our knowledge, this is the first StB training in India. Disparities in access to care, long transport times, and insufficient numbers of prehospital personnel contribute to its significant trauma burden. Dissemination of these critical life-saving skills into this region and the resulting civilian interventions will increase the number of trauma patients who survive long enough to reach a trauma center. Additionally, considerations should be given to translating the course into local languages to increase program reach. LEVEL OF EVIDENCE: Level IV.

Decreased mortality, laparotomy, and embolization rates for liver injuries during a 13-year period in a major Scandinavian trauma center.

BACKGROUND: Although non-operative management (NOM) has become the treatment of choice in hemodynamically normal patients with liver injuries, the optimal management of Organ Injury Scale (OIS) grades 4 and 5 injuries is still controversial. Oslo University Hospital Ulleval (OUHU) has since 2008 performed angiography only with signs of bleeding. Simultaneously, damage control resuscitation was implemented. Would these changes result in a decreased laparotomy rate and need for angioembolization (AE), as well as decreased mortality? METHODS: We performed a retrospective study on all adult patients with liver injuries admitted at OUHU between 2002 and 2014. The total study population and patients with OIS grades 4 and 5 liver injuries underwent comparison between the periods before (P1) and after (P2) August 1, 2008. RESULTS: 583 patients were included (P1: 237, P2: 346), with a median Injury Severity Score (ISS) of 29. The total population and the subgroup of OIS 4 and 5 injuries were comparable in age, gender, mechanism of injury, injury severity and physiology. Overall laparotomy rates decreased from P1 to P2 (35%-24%; p<0.01), as did the AE rate (11%-5%; p<0.01). The 30-day crude mortality decreased from 14% to 7% (p<0.05). A logistic regression model predicted an OR of 0.45 (95% CI 0.21 to 0.98) for dying when admitted in P2. In OIS grades 4 and 5 injuries (n=149, median ISS 34), similar reduction in AE rate was seen (30%-12%; p<0.05). The NOM rate for OIS grades 4 and 5 injuries was 70%, with 98% success rate. For the 30% requiring surgery, the mortality remained high (P1 52%; P2 40%), despite more balanced transfusion strategy. DISCUSSION: Changes in resuscitation and treatment protocols were associated with decreased laparotomy, and AE rates as well as overall mortality. NOM is safe in 70% of patients with OIS grades 4 and 5 injuries, in contrast to the critically ill 30% requiring surgery who still have poor outcome. LEVEL OF EVIDENCE: IV.