What is your target hemoglobin in patients with traumatic brain injury and anemia?
7 g/dL or more
8 g/dL or more
9 g/dL or more
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General Critical Care
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Tranexamic Acid for Traumatic Injury in the Emergency Setting
https://www.annemergmed.com/article/S0196-0644(23)01281-7/fulltext
This study aimed to evaluate the effectiveness of tranexamic acid (TXA) in reducing mortality in emergency trauma cases. A systematic review and meta-analysis of randomized controlled trials were conducted, focusing on TXA's impact compared to a placebo. The main outcome was 1-month mortality. Seven trials met the criteria, and the results showed an 11% decrease in death risk at 1 month with TXA use. There was also a reduction in 24-hour mortality, and no significant increase in vascular occlusive events was observed.
Subgroup analyses indicated that TXA is more effective in general trauma than in traumatic brain injury and is more beneficial when administered out-of-hospital rather than in-hospital. The study concludes that TXA reduces 1-month mortality in emergency trauma cases without significant vascular complications, and its effectiveness varies depending on the type of trauma and the setting of administration.
Tranexamic acid should be routinely given to trauma patients including TBI if no contraindication
0%Agree
0%Disagree
0%Neutral
This study examines the effectiveness and safety of Prothrombin Complex Concentrate (PCC) in treating trauma-induced coagulopathy (TIC) in adult trauma patients. Utilizing a systematic review of MEDLINE and EMBASE databases, the study included nine observational studies and one randomized controlled trial (RCT), covering 1150 patients treated with PCC. The main outcomes were in-hospital mortality and venous thromboembolism (VTE). The results, which combined observational studies and the RCT, indicated that PCC use did not significantly impact mortality rates (odds ratio 0.94) or the risk of deep venous thrombosis (odds ratio 1.00).
For specialists in the trauma field, these findings are significant. They suggest that while PCC does not increase VTE risk, its effectiveness in reducing mortality in TIC patients remains unproven. This uncertainty underscores the need for further comprehensive studies, particularly RCTs, to better understand PCCโs role in trauma care and guide clinical decision-making.
Safety and efficacy of artesunate treatment in severely injured patients with traumatic hemorrhage. The TOP-ART randomized clinical trial
The TOP-ART trial aimed to determine the safety and efficacy of intravenous artesunate in reducing multiple organ dysfunction syndrome (MODS) in trauma patients with major hemorrhage. The trial, however, was terminated early due to safety concerns after enrolling 90 out of the targeted 105 patients. In the 83 patients who received either artesunate (n=54) or placebo (n=29), it was found that serious adverse events (SAEs) were more common in the artesunate group, with 31% (n=17) of patients experiencing SAEs compared to 17% (n=5) in the placebo group.
Furthermore, 17% of the artesunate group experienced venous thromboembolic events (VTE) compared to just 3% in the placebo group. There was no statistical evidence supporting the superiority of artesunate in improving organ dysfunction as measured by the 48-hour SOFA score. The median score was 5.5โฆ
The Restrictive Red Blood Cell Transfusion Strategy for Critically Injured Patients (RESTRIC) trial: a cluster-randomized, crossover, non-inferiority multicenter trial of restrictive transfusion in trauma
This study, known as the Restrictive Transfusion Strategy for Critically Injured Patients (RESTRIC) trial, was designed to investigate the efficacy of red blood cell (RBC) transfusion in patients with severe trauma. Given the uncertainties surrounding optimal hemoglobin target levels during the acute post-injury phase, the trial set out to determine whether a restrictive transfusion strategy would prove clinically non-inferior to a liberal one.
The study involved a cluster-randomized, crossover, non-inferiority design across 22 tertiary emergency medical institutions in Japan. Participants included adult patients at risk of major bleeding from severe trauma. The institutions implemented either a restrictive (hemoglobin targets of 7โ9 g/dL) or liberal (hemoglobin targets of 10โ12 g/dL) transfusion strategy, immediately upon the patients' arrival in the emergency department.
The primary outcome observed was theโฆ
Prehospital Tranexamic Acid for Severe Trauma
What were the findings of the PATCH-Trauma trial regarding the use of tranexamic acid in patients with major trauma and suspected trauma-induced coagulopathy?
0%Improved survival and functional outcomes.
0%Reduced mortality but did not improve functional outcomes.
0%No effect on mortality or functional outcomes.
0%I do not know!
The PATCH-Trauma trial aimed to determine whether the prehospital administration of tranexamic acid, 1 g IV one dose then 1 g infusion for 8 hours, would improve the survival and functional outcomes of patients with major trauma and suspected trauma-induced coagulopathy. The study involved 1,310 patients who were randomly assigned to receive either tranexamic acid or a placebo.
The results showed that there was no significant difference in the percentage of patients with a favorable functional outcome at 76 months after the injury between the tranexamic acid group and the placebo group.
Both groups had similar rates of survival with a favorable functional outcome at 6 months. However, the tranexamic acid group had a lower rate of death within 28 days compared to the placebo group.
The trial confirmed the previous findings that tranexamic acid can reduce mortality in patients with bleeding trauma. Itโฆ
Craniotomy vs. Decompressive Craniectomy for Traumatic Acute Subdural Hematoma
1) What was the research question? The researchers wanted to know whether craniotomy or decompressive craniectomy would lead to better outcomes for patients undergoing surgery for traumatic acute subdural hematoma.
2) How did they do it? They randomly assigned patients to undergo either craniotomy or decompressive craniectomy. They evaluated the patients' outcomes using the Extended Glasgow Outcome Scale (GOSE) at 6 and 12 months, as well as the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L) to assess quality of life.
3) What were the results? They had 450 patients in total, with 228 in the craniotomy group and 222 in the decompressive craniectomy group. The analysis showed no significant difference in outcomes between the two groups at 6 and 12 months. The rates of death, vegetative state, and good recovery were similar, although the craniectomy group had slightly lower rates of good recovery. Quality ofโฆ
Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial
The study investigated the efficacy and safety of administering 4F-PCC in patients at risk of massive transfusion. The study was conducted in 12 designated trauma centers in France, involving consecutive patients with trauma at risk of massive transfusion. The study was a double-blind, randomized, placebo-controlled superiority trial. The primary outcome was 24-hour all blood product consumption, and arterial or venous thromboembolic events were a secondary outcome. The results showed that there was no significant reduction in 24-hour blood product consumption after administering 4F-PCC, and thromboembolic events were more common. The study concluded that the findings did not support systematic use of 4F-PCC in patients at risk of massive transfusion.
Beta blockers in traumatic brain injury: a systematic review and meta-analysis
This article is a systematic review and meta-analysis that examines the role of beta blockers in TBI. The authors searched three databases for studies that compared beta blockers with placebo or no intervention in adult patients with TBI and reported mortality and functional outcome. They included 17 studies with 13โ244 patients and performed pooled analysis and subgroup analysis. They found that beta blockers were associated with lower mortality at acute care discharge and better functional outcome at long-term follow-up, but also with higher rates of cardiopulmonary and infectious complications. They concluded that the evidence for beta blocker use in TBI was very low quality and recommended high-quality randomized trials to further explore this topic.
Hart S, Lannon M, Chen A, Martyniuk A, Sharma S, Engels PT. Beta blockers in traumatic brain injury: a systematic review and meta-analysis. Trauma Surgโฆ
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https://www.nejm.org/doi/full/10.1056/NEJMoa2404360
Population:
- Adults with moderate or severe traumatic brain injury (TBI) and anemia
- Total of 742 patients, with 371 patients in each group
Intervention:
- Liberal transfusion strategy: Transfusions initiated at a hemoglobin level of โค10 g/dL
Comparison:
- Restrictive transfusion strategy: Transfusions initiated at a hemoglobin level of โค7 g/dL
Outcome:
- Primary Outcome: Unfavorable outcome at 6 months assessed by the Glasgow Outcome ScaleโExtended (GOSE)
- Liberal strategy: 68.4% (249/364) unfavorable outcomes
- Restrictive strategy: 73.5% (263/358) unfavorable outcomes
- Adjusted absolute difference: 5.4 percentage points (95% CI, โ2.9 to 13.7)
- **Secondary Outcomes:**
- Mortality: No significant difference
- Functional independence and quality of life: Higher scores on some scales in the liberal strategy group among survivors
- Depression: No significant difference
- Venous thromboembolic events: 8.4% in both groups
- Acute respiratory distress syndrome (ARDS): 3.3% in liberal group, 0.8% in restrictive group
Insights for Medical Intensivists
- Neurological Outcomes: The liberal transfusion strategy did not significantly reduce the risk of unfavorable neurological outcomes at 6 months compared to the restrictive strategy. Both strategies had high rates of unfavorable outcomes, but the difference was not statistically significant.
- Functional Outcomes: Among survivors, some improvement in functional independence and quality of life scores was observed with the liberal transfusion strategy, although this was not consistent across all measures.
- Safety Concerns: The occurrence of venous thromboembolic events was similar in both groups, but the liberal strategy was associated with a higher incidence of ARDS.
- Clinical Practice Implication: Given the lack of significant benefit in neurological outcomes and the increased risk of ARDS with the liberal strategy, a restrictive transfusion strategy might be preferable in critically ill TBI patients with anemia to avoid additional complications without compromising overall survival and functional outcomes.