Surgeons Develop Life-Saving Treatments for Massive Bleeding in Trauma Patients

October 10, 2007 - Surgeons are testing new ways of treating the No. 1 cause of death from trauma in this country - massive bleeding – by deep cooling patients to buy more time for doctors.
Investigators from Massachusetts General Hospital, Boston, are deeply cooling the entire body to prolong the time surgeons have to correct bleeding problems before the brain dies. In their most recent study, the surgical researchers found profound hypothermia effectively treated shock that could not be reversed by standard cardiopulmonary resuscitation, thus saving lives that otherwise would be lost. Findings from this study were reported at the 2007 Clinical Congress of the American College of Surgeons.
“We’re using this strategy in a situation where the alternative is almost certain death,” said Hasan B. Alam, M.D., FACS, associate professor of surgery at Harvard Medical School and a trauma surgeon at Massachusetts General Hospital. “We’re not talking about a scenario where you might decrease the mortality from 10 percent down to 5 percent. We’re talking about a highly lethal model, so we need to do something that is fairly dramatic and outside the box.”
Another study presented at the Clinical Congress highlighted the work of Vanderbilt University, Nashville, TN, where researchers are aggressively treating hemorrhage with a predefined cocktail of blood products to replenish not only the volume of fluid, but also the specific blood components trauma patients lose in the early period after injury. According to findings from this study of massive hemorrhage, the trauma exsanguination protocol (TEP) reduced the odds of mortality by more than 70 percent, saving the lives of patients who were not expected to live, and reducing the number of patients who were expected to die.
In reporting on the Massachusetts General Hospital study, Dr. Alam explained more patients under the age of 34 die of traumatic injuries than of all other diseases combined. He said the No. 1 reason why these patients die is from massive bleeding.
“If you look at autopsy data, most patients have bleeding problems that were fixable,” he said. “We weren’t able to fix them because once patients lose enough blood, they go into cardiac arrest, and the brain dies in about four to five minutes. We simply don’t have enough time to get to the bleeding source and control it.”
Profound cooling of the body decreases the metabolic rate of the brain so it slows down, but does not completely stop. So instead of consuming huge amounts of oxygen, the brain can be kept alive with only small amounts of oxygen delivery. According to Dr. Alam, once the brain is cooled down to about 10 degrees celsius, it can stay alive for about two hours, giving surgeons enough time to fix underlying bleeding problems.
Dr. Alam and his research associates have been testing hypothermia as a treatment for massive blood loss for about five years. In that time, they have determined the optimal rate of cooling and rewarming, the desired depth and duration of cooling, and other practical aspects of the technique through a series of studies.
Their most recent studies have evaluated the effectiveness of hypothermia in an extremely challenging model — a combination of massive blood loss as well as injuries to major organs.
“The goal of this study was to take the technique into a realistic scenario,” Dr. Alam explained. “In the past, we found that the technique worked in models that had no confounding variable other than an injury to a blood vessel, which is easy enough to fix. Once you get to it, you sew it up and you control the bleeding. But what if you have an injury to the abdomen and there is spillage of stool in the abdomen or an injury to the liver or the spleen that continues to spill blood? This study looked at a realistic lifelike trauma scenario.”
The findings were presented at the ACS Clinical Congress last year. This year, they have made the model even more challenging by inducing profound hypothermia in the setting of otherwise “irreversible shock.”
Findings from these studies resolved two major concerns about profound hypothermia: the danger that exposure to profound cooling might precipitate a malfunction in the coagulation process, and that it might reduce immune function and lead to infectious complications.
“We found that cooling causes bleeding, but when the body is cold and bleeding, it is not consuming much oxygen and so it is in a protected state. Once you reverse the hypothermia and warm the body, the bleeding stops,” Dr. Alam said.
His latest study also demonstrates that induction of profound hypothermia can preserve organs and prevent death, even in the setting of advanced shock that does not respond to conventional methods of cardiopulmonary resuscitation and is typically considered “irreversible.”
Dr. Alam and his colleagues at Massachusetts General Hospital as well as researchers at the University of Pittsburgh and other major U.S. trauma centers currently are seeking funding to conduct clinical trials of profound hypothermia in trauma patients. Once they obtain financial support, they should be able to begin clinical trials in about a year or two, he predicted.
The trauma exsanguination protocol used by trauma surgeons at Vanderbilt University Medical Center addresses massive blood loss by assuming the patient is coagulopathic upfront and presumptively treating them, according to Brigham K. Au, BA, a third-year medical student. Patients who are so severely injured that they need a transfusion of 10 or more units of blood typically receive infusions of red blood cells to replace the blood they have lost. Many times, however, patients bleed out what they are given because the transfusions do not contain sufficient amounts of blood products to stimulate coagulation.
The Vanderbilt protocol, developed by a multidisciplinary group of surgeons, anesthesiologists, and transfusion medicine specialists, calls for the hospital blood bank to prepare packets of red blood cells, platelets, and fresh frozen plasma in predefined ratios and continue to replenish these 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.
“We use a tighter ratio so we can stop the bleeding up front in an effort to limit the total blood products needed to reduce the amount of fluid necessary to control the patient’s cardiovascular stability,” Au explained.
When trauma surgeons at Vanderbilt University Medical Center evaluated outcomes after they instituted a transfusion protocol that replaced the blood trauma patients had lost and at the same time instituted coagulation, they found there were more unexpected survivors and fewer unexpected deaths. The survival rate was 15 percent higher in patients who received the exsanguination protocol with an unexpected survivor rate of 20.3 percent (compared to only 5.7 percent for patients who did not receive the TEP). As well, the rate of unexpected deaths was 14 percent lower (2.9 percent versus 17.1 percent).
The study included 139 patients; 69 were treated under the TEP and 70 were treated before the TEP was instituted. The differences in outcome were statistically significant. Unexpected survival and unexpected death in this 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.
The protocol also decreased the amount of fresh frozen plasma and platelets that were needed in the first 24 hours of treatment.