November 2, 2007

New treatment boosts odds of survival following trauma

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Bryan Cotton, M.D.

New treatment boosts odds of survival following trauma

Chances of surviving a car accident or other traumatic injury where large amounts of blood are lost are increasing thanks to research conducted by trauma specialists at Vanderbilt University Medical Center.

The Trauma Exsanguination Protocol (TEP), led by Bryan Cotton, M.D., assistant professor in the Division of Trauma and Surgical Critical Care, involved administering — early in the treatment process — an aggressive regimen that included a cocktail of blood products.

The study demonstrated the new protocol reduced the odds of death by more than 70 percent.

TEP has proven effective on patients who are severely injured and need transfusions of 10 or more units of blood. Previous experience has shown that many patients bleed to death because the transfusions given do not contain sufficient amounts of appropriate blood products to stimulate coagulation.

“Giving clotting factors and platelets with blood early in the care of patients with life-threatening hemorrhage (as opposed to the "traditional" method of saline, more saline, blood, then adding clotting factors and platelets later on) results in improved survival,” Cotton said.

Cotton is the lead author of the study, which will appear in the January 2008 issue of Journal of Trauma.

The TEP study, which included 211 patients, has already resulted in changes in the way Vanderbilt Trauma surgeons are treating their patients.

“We have recently changed the way we approach these patients and have an active protocol in place that is evaluated on a quarterly basis to look for ways to improve and adjust to our institutional needs,” he said.

The new protocol has proven so compelling that the U.S. Army is interested in reviewing strategies that could help with battlefield treatment of its soldiers.

“The U.S. Army Institute of Surgical Research has approached us for our input and involvement in a study of resuscitation strategies of patients with active hemorrhage requiring massive blood transfusion,” Cotton explained.

The Vanderbilt protocol calls for the hospital blood bank to prepare packets of red blood cells, platelets, and fresh frozen plasma in predefined ratios. The blood is replenished every 20 to 30 minutes until a patient is stabilized.

“The ratios of blood components (plasma and platelets) are more closely approximate to that of blood being lost than what is considered 'standard' transfusion practice at most trauma centers,” Cotton explained.

The survival rate in patients who underwent the TEP was 15 percent higher than those patients who didn't, with an unexpected survivor rate of 20.3 percent (compared with only 5.7 percent for patients who did not receive the TEP). The rate of unexpected deaths was 14 percent lower.

In addition to increased survival, the new protocol showed patients required less blood and blood products.

Unexpected survival and unexpected death in the study were defined by the Trauma Related Injury Severity Score (TRISS) Methodology, which determines the probability of survival on the basis of the severity of injury, the patient's condition on admission to the hospital and age.

Cotton was assisted in this research by faculty from Vanderbilt and the Tennessee Valley VA Medical Center including; Vanderbilt's Division of Trauma & Surgical Critical Care, Department of Anesthesiology, Department of Pathology, Department of Transfusion Medicine and Hematology.

Contributing researchers included: Oliver Gunter, M.D., James Isbell, M.D., Brigham K Au, B.S., Amy Robertson, M.D., John Morris Jr., M.D., Paul St. Jacques, M.D., and Pampee Young, M.D., Ph.D.