Over the last decade the age of trauma patients and injury mortality have increased, and in the same period many centres have implemented multiple interventions focused on improved haemorrhage control, effectively resulting in a bleeding control bundle of care. In order to investigate the temporal distribution of trauma-related deaths, the factors that characterise that distribution and how those factors have changed over time at an urban level 1 trauma centre, the authors reviewed patient records from two time periods, 2005-2006 (7080 patient records, 498 deaths) and 2012-2013 (8767 patient records, 531 deaths). These periods of time represent two years before and after implementation of major changes in control of bleeding and early resuscitation procedures at the centre.
The main finding was that from the first to the second period, the median age of all patients increased by 6 years, with a similar increase in deaths with traumatic brain injury (TBI) and haemorrhage accounting for >91% of all deaths. From 2006-2006 to 2012-2013, TBI (61%) and multiple organ failure or sepsis (6.2%) were unchanged whereas haemorrhagic deaths decreased from 36% to 25%. In both time periods, 26% of all deaths occurred within one hour of hospital arrival while 59% occurred within 24 hours. Looking at one-hour mortality, the primary cause of death changed from haemorrhage (60.3%) followed by head injury (37.5%) in 2005-2006 to mostly head injuries (52.7%) followed by haemorrhage (38%) in 2012-2013. Furthermore, adjusted mortality dropped by 24% (from 7.6% to 5.8%) and in-hospital mortality dropped by 30% (from 6.6% to 4.7%).
Based on this, the authors conclude that the observed decrease in mortality in this single-centre study was due to decreased haemorrhagic deaths. This decrease is in contrast to the general increase in trauma deaths reported across the globe in the same period, and the authors argue that efforts focused on haemorrhage control interventions – a bleeding control bundle – may explain this finding, and that this may provide guidance for future prevention and intervention efforts.
The study origins from a US centre that since 2008 has focused on optimal resuscitation and stopping bleeding, employing multiple methods in the prehospital and hospital areas of care, resulting in a bleeding control bundle of care comprising identification of the bleeding patient, prehospital and hospital damage control resuscitation, prehospital and hospital extremity and junctional tourniquets, prehospital and hospital pelvic binders, prehospital and hospital haemostatic dressings, resuscitative endovascular balloon occlusion of the aorta, coagulation monitoring by thrombelastography, tranexamic acid for patients with significant fibrinolysis, decreased time to OR, decreased time to interventional radiology and goal-directed resuscitation with blood products as bleeding slows. The study nicely documents that implementation of a bleeding control bundle has a great potential to reduce trauma mortality.
– Sisse Rye Ostrowski