Advancing Trauma Care

from left to right: Avery Nathens, Russell Gruen, and Sandro Rizoli

Russell Gruen, Director of the National Trauma Research Institute and Professor of Surgery and Public Health at the Alfred and Monash University, in Melbourne, Australia presented University Trauma Rounds on Friday, June 7th.

Russell is a general and trauma surgeon with a keen interest in public health. When he was still in training in General Surgery at the University of Melbourne, he completed a PhD on the effectiveness of specialist outreach clinics for remote indigenous communities in Northern Australia. He received a Harkness Fellowship in Healthcare Policy, during which he focused on international health policy, healthcare systems research, and medical professionalism. The fellowship took him to Harvard University where he was also a Fellow in the medical ethics program. He helped to formulate the American College of Surgeon’s code of professional conduct. Russ received his trauma training at Harborview Hospital in Seattle, where he studied under Avery Nathens, as the Fellowship Program Director. Russ told us that Melbourne is similar to Toronto in population, and in having two major trauma centers. He demonstrated the effect of various legislative interventions on reducing the mortality from vehicular trauma (Fig. 1). In recent years, much of this progress is due to the Victorian State Trauma System.

Figure 1

He then discussed the perioperative management of the anti-coagulated patient. Patients taking Warfarin are commonly encountered in surgical practice, and the management of their anti-coagulation during surgery can be suboptimal. In his study of 108 hernia patients at his own hospital, 30% of those who were “bridged with low-molecular weight heparin” had significant bleeding events in the postoperative interval. Bridging as currently practiced with low molecular weight heparin is clearly problematical. Many surgeons, particularly vascular surgeons, now operate without interrupting anticoagulation. Alternative protocols for Warfarin reversal, using Vitamin K, or Prothrombinex, also exist, and there is a need now to evaluate the safety and efficacy of these in comparison to current guidelines that use LMWH.

The protocol that he recommends includes vitamin K, given the night before to get the INR to 1.5. He presented an excellent summary of the coagulation and fibrinolysis mechanisms, and the pro-coagulants - hemostatic adjuncts for the surgeon in current use, including the recently introduced topical dressings which deliver thrombin and fibrinogen to the site of bleeding. Newer preparations include the fibrin pad which can locally control a 4 mm hole in the aorta in animal models. He discussed the coagulopathy induced by the combination of trauma, acidosis, and hypothermia, and the interaction with the fibrinolytic mechanism. Systemic treatment for trauma-induced coagulopathy includes fresh frozen plasma, cryoprecipitate, fibrinogen, Prothrombin Complex, factor 7A and antifibrinolytics like Tranexamic acid, and aminocaproic acid.

“In the Crash 2 study of 20,000 patients (www.thelancet. com/crash-2), tranexamic acid reduced bleeding deaths in a multi-country study. From our perspective, the study was limited in that only 2% of the patients came from countries with advanced trauma care that included treatments for coagulopathy with blood products, rapid control of bleeding, and advanced prehospital and critical care. The remainder came from countries with less well developed systems, most of which didn’t have advanced prehospital care and or a reliable blood supply. Given that the mortality rate of severely injured patients in Toronto is about half that of the centres in CRASH-2, it is unlikely that significant mortality benefit will be achieved in Toronto with tranexamic acid. The high incidence of bleeding in both arms of the study probably account for the observation that tranexamic acid reduced bleeding deaths. From an observational study in the military, we learned that tranexamic acid was associated with much higher (9 to 12 times) the incidence of pulmonary embolism and deep venous thrombosis compared to control patients. Therefore, there is a need to investigate effectiveness and safety concerns in advanced systems, such as the Toronto trauma system.” The PATCH-Trauma trial is planned to evaluate the pre- hospital administration of tranexamic acid vs. placebo at the scene of injury in similar systems.

M.M.