| Abstract|| |
Background: Blood transfusion therapy (BTT), which represents transplantation of living cells, poses several risks. Although BTT is necessary for trauma victims with hemorrhagic shock, it may be futile for patients with blunt traumatic cardiopulmonary arrest (BT-CPA). Materials and Methods: We retrospectively examined the medical records of consecutive patients with T-CPA. The study period was divided into two periods: The first from 1995-1998, when we used packed red cells (PRC) regardless of the return of spontaneous circulation (ROSC), and the second from 1999-2004, when we did not use PRC before ROSC. The rates of ROSC, admission to the ICU, and survival-to-discharge were compared between these two periods. Results: We studied the records of 464 patients with BT-CPA (175 in the first period and 289 in the second period). Although the rates of ROSC and admission to the ICU were statistically higher in the first period, there was no statistical difference in the rate of survival-to-discharge between these two periods. In the first period, the rate of ROSC was statistically higher in the non-BTT group than the BTT group. However, for cases in which ROSC was performed and was successful, there were no statistical differences in the rate of admission and survival-to-discharge between the first and second group, and between the BTT and non-BTT group. Conclusion: Our retrospective consecutive study shows the possibility that BTT before ROSC for BT-CPA and a treatment strategy that includes this treatment improves the success rate of ROSC, but not the survival rate. BTT is thought to be futile as a treatment for BT-CPA before ROSC.
Keywords: Blood transfusion therapy, return of spontaneous circulation, survival to discharge, traumatic cardiopulmonary arrest
|How to cite this article:|
Moriwaki Y, Sugiyama M, Tahara Y, Iwashita M, Kosuge T, Toyoda H, Arata S, Suzuki N. Blood transfusion therapy for traumatic cardiopulmonary arrest. J Emerg Trauma Shock 2013;6:37-41
|How to cite this URL:|
Moriwaki Y, Sugiyama M, Tahara Y, Iwashita M, Kosuge T, Toyoda H, Arata S, Suzuki N. Blood transfusion therapy for traumatic cardiopulmonary arrest. J Emerg Trauma Shock [serial online] 2013 [cited 2020 Sep 19];6:37-41. Available from: http://www.onlinejets.org/text.asp?2013/6/1/37/106323
| Introduction|| |
Blood transfusion therapy (BTT) is the transplantation of living cells and thus includes several risks, such as infection, inflammation, and undesirable immuno-chemical reactions. BTT should be thought of as having been derived from precious material, thanks to the courtesy of donors. The proper use of blood products and strict indications for BTT must be carefully considered. However, patients with severe trauma with hemorrhagic shock always require an immediate massive blood transfusion in order to survive.  Patients with blunt traumatic cardiopulmonary arrest on arrival at the hospital (BT-CPA) usually suffer from lethal hemorrhage and require a rapid supplement of red blood cells to resuscitate circulation and oxygen transport. However, it is known that BT-CPA patients have a very low chance of survival, , even when given sufficient BTT to compensate for the blood loss. Performing BTT for BT-CPA patients may be futile. The aim of this study was to evaluate the appropriateness of our strategy concerning BTT for BT-CPA patients.
| Materials and Methods|| |
We retrospectively examined the medical records of consecutive patients with BT-CPA and the treatments, including blood transfusion, administered to them at our hospital over the past 10 years. Patients whose treatment was started on the scene by an organized medical team including doctors were excluded. Until 1998, we used packed red cells (PRC) without any restrictions for BT-CPA patients, regardless of the return of spontaneous circulation (ROSC), if we thought it necessary to use these blood products. During this period of time, the administration of these treatments might have been biased based on the suspected chance of survival, i.e., based on the victim's age, a suspiciously relatively small quantity of blood loss, the co-existence of a pneumothorax or hemothorax, or the interval of time from the event (i.e., brief). However, we could not evaluate the details of the anatomical injuries of all BT-CPA patients because we did not perform sufficient imaging to obtain findings, resulting in incomplete descriptions of their ISS. In addition, we could not accurately evaluate pneumothorax because we usually performed emergency department thoracotomy just after arrival at the emergency department (ED). After 1999, we used PRC on a case-by-case basis, but only after ROSC in principle.
The study period was divided into the following two intervals: The first period was from 1995-1998 and the second from 1999-2004. To clarify the effect of the treatment strategy regarding BTT before ROSC during CPR on the outcome of BT-CPA, the success rates of ROSC, admission to the ICU (or directly to the operating room or angiography room) after ROSC, and survival-to-discharge were compared between these two periods. To clarify the effect of BTT before ROSC on the outcome of BT-CPA, these rates were compared within the first period between the group of patients who underwent BTT (BTT group) and the group who did not undergo BTT (non-BTT group) before ROSC.
The study was conducted in a part of Yokohama city in the Yokohama triage and transfer system for CPA patients, which serves all out-of-hospital cases of CPA of traumatic and non-traumatic origin. Yokohama is the second-largest city in Japan (with a surface area of 434 km 2 and a population of 3.37 million), and our institute is located in the city center. We selected 11 hospitals, including our hospital, which had EDs that could receive and treat all patients with traumatic and non-traumatic CPA, independent of their capacity and without any exceptions. One emergency director (medical doctor), who works for the city's fire department, co-ordinates the activities of ambulance crews, including emergency life-saving technicians (ELST), and oversees the transfer of CPA patients to the nearest of the 11 selected hospitals. ,, In Yokohama, for each hospital, all CPA patient data are population-based. Under our EMS system, the response interval (the time between the ambulance's departure from the fire station to its arrival at the scene) for CPA cases is 6.0 minutes (2.3 km in distance), the on-scene interval for CPA cases (the interval between the arrival at the scene and the departure from it) is 12.9 minutes, and the interval from the departure from the scene to arrival at the ED is 7.2 minutes (4.6 km), on an average.
To evaluate the statistical differences between the first and second periods and between the BTT and non-BTT groups, we used the student's t test and χ2 test.
| Results|| |
In 464 BT-CPA patients (175 in the first period and 289 in the second period), 44.6% achieved ROSC, 22.9% were admitted to the ICU, 3.4% survived to discharge in the first period and 28.0%, 14.9% and 2.4% in the second period, respectively. In the first period, PRC were used for 29 non-survivors (139 units for 23 cases without ROSC, 6 units for 3 cases with ROSC without admission, and 18 units for 3 cases with admission) before their ROSC. In the second period, no PRC were used for non-survivors before ROSC.
The mean age of the cases in the first period was 46.1 years old and that of the second period was 42.3 years old; the former group was statistically older than the latter (P = 0.05). Witnessed CPA, CPA after the scene, and CPA with some cardiac rhythm on the scene were 78.9%, 22.9%, and 39.4% in the first period and 76.8%, 18.3%. and 32.5% in the second period, respectively, and there were no statistical differences. The mean time interval between the event and arrival at the ED were 24.1 minutes in the first period and 27.9 minutes in the second period; the former was statistically shorter than the latter (P = 0.02). The mean time interval between arrival at the ED and ROSC of 81 patients in the first period was 13.9 minutes and that of 78 patients in the second period was 11.8 minutes; there was no statistical difference. In the first period, 29 achieved ROSC within 10 minutes (37.2% of 78 patients with ROSC) and 36 in the second period (44.4% of 81 patients with ROSC). There was no statistical difference between the two periods [Table 1].
|Table 1: The background and the number of cases with ROSC, cases admitted into ICU and surviving cases in whole cases, witnessed CPA cases, CPA after scene and CPA on the scene with electrical cardiac rhythm; the first period and the second period |
Click here to view
With respect to the effect of the BTT strategy on the outcome of BT-CPA in all cases, the success rate of ROSC and admission to the ICU were statistically higher in the first period than in the second (P = 0.0003 and 0.0298). However, there was no statistical difference in the rate of survival-to-discharge between the first and second periods. In cases in which ROSC was successful, there was no difference between these two groups. The same tendency was observed in the witnessed cases. In cases with some electrical rhythm on the electrocardiogram (ventricular fibrillation or pulseless electrical activity) on the scene, only the rate of ROSC was statistically higher in the first period than in the second period (P = 0.0094). However, there was no statistical difference in all prognostic parameters in cases with CPA occurring after the scene of the injury [Table 1] and [Figure 1].
|Figure 1: The differences of the rate of successful ROSC, admission (Adm.) into ICU, and survival-to-discharge (Surv.) between the first and the second period, (a) the rate against all cases and (b) restricted in cases with successful ROSC, the rate of cases with admission and surviving cases against the cases with ROSC|
Click here to view
In the first period alone, the success rate of ROSC was statistically higher in the non-BTT group than in the BTT group in all cases and in the witnessed cases (P = 0.0046 and 0.0048). However, there was no statistical difference in the rate of admission to the ICU and survival-to-discharge between these groups. In the cases after successful ROSC, there was no difference between these two groups in all situations. The mean time interval between the event and arrival at the ED were 24.4 minutes in the non-BTT group and 22.6 minutes in the BTT group. The mean time interval between arrival at the ED and ROSC of 72 patients with ROSC of the non-BTT group were 12.6 minutes and that of 6 patients of the BTT group was 29.0 minutes. There was a statistical difference between the two groups (P < 0.0001). Twenty-seven achieved ROSC within 10 minutes in the non-BTT group (37.5% of 72 patients with ROSC) and one in the BTT group (16.7% of 6 patients with ROSC) [Table 2] and [Figure 2].
|Figure 2: The differences of the rate of successful ROSC, admission (Adm.) into ICU, and survival-to-discharge (Surv.) between the BTT group and non-BTT group, (a) the rate against all cases and (b) restricted in cases with successful ROSC, the rate of cases with admission and surviving cases against the cases with ROSC|
Click here to view
|Table 2: The background and the number of cases with ROSC, cases who admitted into ICU and surviving cases in whole cases, witnessed CPA cases, CPA after scene and CPA on the scene with electrical cardiac rhythm; the BTT group and the non-BTT group in the first period |
Click here to view
| Discussion|| |
The survival rate of BT-CPA is poor, reportedly only 0% to 3.7%. ,,,, Some authorities consider resuscitation treatment of this patient group, including aggressive infusion, resuscitation thoracotomy, and BTT, to be futile and inappropriate. The National Association of EMS Physicians Standards and Clinical Practice Committee and the American College of Surgeons Committee on Trauma have published guidelines for withholding or terminating resuscitation attempts in pre-hospital traumatic cardiopulmonary arrest (NAEMSP/ACSCOT guidelines) in a joint position paper.  According to these guidelines, some treatment efforts to resuscitate BT-CPA patients seemed to be futile. However, it has been reported that some survivors, who were not to be resuscitated if they were evaluated according to the NAEMSP/ACSCOT guidelines, ,, and these guidelines do not address the effectiveness or futility of BTT for BT-CPA.
BTT is a useful but risky treatment for hemorrhagic shock patients, and may worsen the outcomes of some categories of patients. Recently, the German Trauma Society suggested that massive blood transfusion of more than 10 units of PRC was one of the highest risk factors for the mortality of patients with BT-CPA.  However, this report did not show any benefit or risk of BTT before ROSC during CPR in BT-CPA patients in terms of ROSC, ICU admission, or survival-to-discharge. Our study did not show any benefit of BTT for the survival-to-discharge of BT-CPA patients, although it showed the possibility that the success rate of ROSC can be improved.
Our historical case series showed some benefit of a treatment strategy with BTT before ROSC in the success rate of ROSC and in admission to the ICU. There was no fundamental difference in our treatment concepts and strategy for BT-CPA before ROSC between the first and second periods, except BTT before ROSC during CPR. On the other hand, during the second period there were many improvements in terms of knowledge and instruments in the fields of emergency medicine, traumatology, and intensive care that had not been common and standard during the first period. Despite these developments, the success rate of ROSC and admission to the ICU were worse in the second period in which we did not perform BTT before ROSC than in the first period in which we did. If we adopt the rate of survival-to-discharge as the primary outcome, then we have to conclude that treatment strategies for BT-CPA that include BTT before ROSC are futile. Our data also showed that although the treatment strategy of BTT before ROSC improved the success rate of ROSC, whether BTT was used before ROSC or not during CPR did not affect the outcome in cases in which ROSC was achieved. Although BTT strategies after ROSC were the same in both periods, we could not evaluate the effect of BTT after ROSC because we could not differentiate "BTT after ROSC" from "BTT performed during hospitalization from admission to discharge", particularly in surviving cases.
Against our expectation, our study in the first period concerning the relationship between BTT before ROSC and patient outcomes showed that BTT itself did not improve the success rate of ROSC, admission to the ICU, or survival rate. During this period, physicians freely selected BTT if they felt it was necessary, and there was no protocol and no restrictions for performing BTT, resulting in the tendency to perform BTT for severer patients not expected to achieve ROSC and survive-to-discharge. In fact, the mean time interval between the event and arrival at the ED was longer in the BTT group than in the non-BTT group, which might mean the patients in the BTT group were more severely injured and could achieve ROSC after long CPR, even with BTT. However, we did not and could not perform BTT for patients who achieved ROSC very shortly after arrival at the ED before deciding and performing BTT. And they were expected to have a better prognosis because their quick ROSC and short collapse. The patients with a better prognosis in the non-BTT group might increase the rate of ROSC and the survival rate. In this study, some patients achieved ROSC after just a short CPR in the non-BTT group, and underwent BTT after ROSC.
Under the free BTT concept in the first period, it is possible that BTT was performed even for patients who archived ROSC after long CPR without BTT and without noticing appropriate hemostatic procedures. It is also possible that BTT was not performed even after ROSC in the second period, because the strategy physicians followed during that period was to restrict using BTT before ROSC because it was futile to do so. Although the strategies for BTT after ROSC were basically the same in the first and second periods, BTT was performed only for BT-CPA patients with a higher expectancy of survival in some cases. We reported in our previous study that the prognosis of BT-CPA with some cardiac rhythm on the scene and with a shorter interval between the event and arrival at the ED was better. Patients with a poor prognosis in the non-BTT group might have decreased the success rate of ROSC and survival rate in this study. However, we were not able to show these biases between the first and second periods and between the non-BTT and BTT groups.
In any case, we concluded that BTT before ROSC during CPR does not improve the survival rate of BT-CPA, and may in fact be futile. The data presented here shows that BTT before ROSC itself is futile, but that a strategy that includes BTT before ROSC can improve the success rate of ROSC, and increase admission to the ICU. There may have been an emotional bias in these two periods; in other words, in the first period, we treated BT-CPA patients more aggressively with BTT without sufficient evaluation of the possibility of survival, while in the second period, we gave up resuscitating patients during the early phase of treatment because use of BTT was restricted.
Because it is difficult to complete a controlled prospective study for such critical and rare cases as BT-CPA, this study has several limitations. First, the prognosis of BT-CPA is extremely poor, and it is thus difficult to compare the survival rate as the primary endpoint between two periods or between non-BTT and BTT groups. Second, we did not consider the effect of BTT after ROSC in both periods. Third, our indication of BTT before ROSC during CPR in the first period was relative, resulting in a great difference between the condition and background of the two groups. Moreover, patients with quick ROSC could not undergo BTT before ROSC if we thought it necessary to perform BTT for them.
BTT is one of the most effective therapies for exsanguination, anemia, thrombocytopenia, and coagulopathy. However, it is one of the riskiest treatments because it is a type of transplantation of raw material containing living cells. Moreover, it should be thought of as a treatment strategy using very precious material made available through voluntary self-sacrifice, and its utilization should be restricted. We must responsibly preserve and properly redistribute these precious resources. Although we appeared to waste PRC in the first period, after the second period, we narrowed the indications for BTT, resulting in comparably proper use. However, it is still necessary to perform appropriate and active resuscitation for BT-CPA patients, and to do our utmost to save their lives. Other guidelines should be developed on the appropriate use of PRC, to avoid wasting these precious blood products.
| Conclusions|| |
Our retrospective consecutive study shows the possibility that BTT before ROSC for BT-CPA and a treatment strategy that includes these treatments improves the success rate of ROSC, but not the survival rate. BTT is thought to be futile as a treatment for BT-CPA before ROSC.
| References|| |
|1.||Moriwaki Y, Suzuki N, Sugiyama M. Uncrossmatched Red Cell Concentrate Transfusion for Abdominal Injury with Hemorrhagic Shock. Jpn J Gastroenterol Surg 2009;42:147-53. |
|2.||Moriwaki Y, Sugiyama M, Suzuki N. Outcome of blunt traumatic cardiopulmonary arrest. Intens Care Med 2007 Suppl;33:S269. |
|3.||Moriwaki Y, Sugiyama M, Kosuge T, Toyoda H, Inari H, Suzuki N. Outcome of traumatic cardio-pulmonary arrest due to penetrating trauma. Intens Care Med 2006 Suppl;32:S210. |
|4.||Moriwaki Y, Sugiyama M, Hayashi H, Mosiello G, Cremonese F, Altomani V, et al. Emergency medical service system in Yokohama, Japan. Annali Degli Ospedali San Camillo e Forlanini 2001;3:344-56. |
|5.||Moriwaki Y, Sugiyama M, Toyoda H, Kosuge T, Tahara Y, Suzuki N: Cardiopulmonary arrest on arrival due to penetrating trauma. Ann R Coll Surg Engl 2010;92:142-6. |
|6.||Moriwaki Y, Sugiyama M, Yamamoto T, Toyoda H, Kosuge T, Harunari N, et al. Outcomes from prehospital cardiac arrest in blunt trauma patients. World J Surg 2010;35:34-42. |
|7.||Pickens JJ, Copass MK, Bulger EM. Trauma patients receiving CPR: Predictors of survival. J Trauma 2005;58:951-8. |
|8.||Hopson LR, Hirsh E, Delgado J, Domeier RM, McSwain NE Jr, Krohmer J; National Association of EMS Physicians Standards and Clinical Practice Committee; American College of Surgeons Committee on Trauma. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest: A joint position paper from the National Association of EMS Physicians Standards and Clinical Practice Committee and the American College of Surgeons Committee on Trauma. J Am Coll Surg 2003;196:106-12, Prehosp Emerg Care 2003;7:141-6. |
|9.||Cera SM, Mostafa G, Sing RF, Sarafin JL, Matthews BD, Heniford BT. Physiologic predictors of survival in post-traumatic arrest. Am Surg 2003;69:140-4 |
|10.||Rosemurgy AS, Norris PA, Olson SM, Hurst JM, Albrink MH. Prehospital traumatic cardiac arrest: The cost of futility. J Trauma 1993;35:468-74. |
|11.||Mazzorana V, Smith RS, Morabito DJ, Brar HS. Limited utility of emergency department thoracotomy. Am Surg 1994;60:516-21. |
|12.||Willis CD, Cameron PA, Bernard SA, Fitzgerald M. Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile. Injury 2006;37:448-54. |
|13.||Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: Who are the survivors? Ann Emerg Med 2006;48:240-4. |
|14.||Huber-Wagner S, Lefering R, Qvick M, Kay MV, Paffrath T, Mutschler W, et al. Working Group on Polytrauma of the German Trauma Society (DGU). Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest. Resuscitation 2007;75:276-85. |
Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2]