Survival of Bleeding Trauma Patients
The discovery of Acute Traumatic Coagulopathy (ATC, a syndrome of abnormal clotting after trauma) by Professor Brohi’s team at the Blizard Institute in 2000, has led to a new understanding of why patients bleed to death after severe injury and resulted in a fundamental change in resuscitation strategy for acute bleeding patients (Damage Control Resuscitation or DCR) that has led to 250–300 per cent improved survival in massively bleeding trauma patients.
The science: the discovery of ATC
Trauma remains one of the world’s biggest contributors to the global burden of disease. The increasing burden is highest in young adults and children, with 90,000 deaths each year in people under 30, half of which are due to bleeding.
In 2000, Prof. Brohi’s team performed a study analysing blood samples from trauma patients brought in by the Air Ambulance Service at Barts Hospital. He identified that one in four patients already had ATC on arrival and that, if present, it was associated with a four-fold increase in mortality. The team showed that ATC is caused by an abnormal response to severe trauma and blood loss due to which blood clots are poorly formed and rapidly broken down. Standard tests of clotting in trauma are not available in a timeframe that is able to effectively guide management in these rapidly bleeding patients. Furthermore, since ATC is primarily a problem of clot strength and clot breakdown, standard laboratory clotting tests are insensitive to its presence. They have also shown that it is impossible reliably to clinically predict who will get ATC and need a transfusion. However, Prof. Brohi’s group have shown that a newer diagnostic device can identify patients with ATC within five minutes of arrival in the A&E department and have determined a diagnostic threshold for this condition.
Putting research into action: impact on survival and clinical guidelines
Based on the scientific evidence, both the USA and UK Surgeon Generals issued ‘general standing orders’ during the wars in Iran and Afghanistan that the management of severe haemorrhage should target ATC. The US Air Force General subsequently testified to the US Senate that this resuscitation approach had saved lives. Our work in developing a DCR transfusion protocol called ‘Code Red’ has now been adopted by all major trauma centres in London and is being adopted nationally and internationally. This coagulation-centric approach has been incorporated into UK national transfusion guidelines and new European Guidelines on the management of major haemorrhage. The global Advanced Trauma Life Support Manual updated in 2012 includes ATC-targeted therapy in its protocols.
In response to Prof. Brohi’s work showing that a newer diagnostic device can identify patients with ATC within five minutes of arrival in A&E, manufacturers are developing a new generation of devices. In particular, one manufacturer has developed a ‘ruggedised’ version of their device that has been deployed in Camp Bastion in Afghanistan as well as in other conflict zones around the world.