The acute management of trauma hemorrhage: a systematic review of randomized controlled trials
1 NHS Blood and Transplant, Oxford Radcliffe Hospitals NHS Trust and University of Oxford, Headley Way, Oxford, OX3 9BQ, UK
2 Systematic Review Initiative (SRI), NHS Blood and Transplant, John Radcliffe Hospital, Oxford, Headley Way, Oxford, OX3 9BQ, UK
3 UK Cochrane Centre, 18-24 Middle Way, Summertown, Oxford, OX2 7LG, UK
4 Peninsula Technology Assessment Group (PenTAG), Peninsula College of Medicine and Dentistry, University of Exeter, EX2 4SG, UK
5 Trauma Sciences, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, E1 4NS, UK
Critical Care 2011, 15:R92 doi:10.1186/cc10096Published: 9 March 2011
Worldwide, trauma is a leading cause of death and disability. Haemorrhage is responsible for up to 40% of trauma deaths. Recent strategies to improve mortality rates have focused on optimal methods of early hemorrhage control and correction of coagulopathy. We undertook a systematic review of randomized controlled trials (RCT) which evaluated trauma patients with hemorrhagic shock within the first 24 hours of injury and appraised how the interventions affected three outcomes: bleeding and/or transfusion requirements; correction of trauma induced coagulopathy and mortality.
Comprehensive searches were performed of MEDLINE, EMBASE, CENTRAL (The Cochrane Library Issue 7, 2010), Current Controlled Trials, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and the National Health Service Blood and Transplant Systematic Review Initiative (NHSBT SRI) RCT Handsearch Database.
A total of 35 RCTs were identified which evaluated a wide range of clinical interventions in trauma hemorrhage. Many of the included studies were of low methodological quality and participant numbers were small. Bleeding outcomes were reported in 32 studies; 7 reported significantly reduced transfusion use following a variety of clinical interventions, but this was not accompanied by improved survival. Minimal information was found on traumatic coagulopathy across the identified RCTs. Overall survival was improved in only three RCTs: two small studies and a large study evaluating the use of tranexamic acid.
Despite 35 RCTs there has been little improvement in outcomes over the last few decades. No clear correlation has been demonstrated between transfusion requirements and mortality. The global trauma community should consider a coordinated and strategic approach to conduct well designed studies with pragmatic endpoints.