Critical Best Practice

"If you are bleeding from a hole in your liver, and on top of that your body cannot form good clots, it's a bad combination.
Until 2007, "a patient would come in bleeding, you would try to stop the bleeding and at the same time start intravenous saline -- nothing more than water and salt. If the blood work showed your patient needs blood, you would give blood."
Dr. Sandro Rizoli, director, trauma program, St. Michael's Hospital, Toronto

A new study published in the Canadian Medical Association Journal co-authored by Dr. Rizoli brings into question what has become standard routine in transfusing trauma patients. Prior to 2007 it was standard procedure in trauma centres around the world in treating car crash victims, for example, to give intravenous saline comprised of water and salt. Blood was transfused only if tests indicated anemia from  loss of blood, or improper clotting was resulting from medical trauma.

But then, in 2007 American military doctors operating within war theatres in Iraq and Afghanistan noted their observations that wounded soldiers seemed likelier to survive their trauma injuries if attending doctors immediately began transfusing large amounts of blood, rather than waiting for blood-testing results before proceeding. The U.S. military study altered the manner in which trauma centres worldwide resuscitated their patients.

"The standard became to treat patients with a big bleed by assuming they're not clotting and immediately transfusing with blood", explained Dr. Rizoli. A combination of equal parts red blood cells, plasma -- the liquid part of blood containing clotting factors -- and platelets, responsible for giving blood its sticky values making it more likely to form clots, comprised the transfusion.

Recently, however, the new Sunnybrook Health Sciences Centre study compared blood-based resuscitation as opposed to what was once conventional resuscitation to discover that blood waste and medical complications in patients automatically transfused with blood resulted. Additionally, there was no difference detected in rates of death from use of either method.

Among trauma patients, hemorrhage is recognized as the leading cause of preventable, in-hospital deaths. Dr. Rizoli's team conducted randomized trials of the formula in trauma patients. Their study indicated blood wastage and greater respiratory complications requiring that patients be connected to mechanical ventilators with the blood-transfusion formula. And a negligible difference in rates of death resulting.

Minutes after a major trauma as for example, car accident, a serious fall sustaining gross injuries from a height, gunshot or stab wounds, one-quarter of patients fail to clot adequately. While in a trauma medical state, their bodies release huge amounts of natural substances that have the effect of preventing clots from forming. And this is a condition that increases the risk of bleeding to death.

Seems as though there's never a final word in medical-scientific treatment. New procedures in response to life-threatening events often become widely accepted when they are held to be superior in outcome to earlier methods. But sometimes what is popularly believed to be so, just isn't. Just take the example of teaching people the long-accepted technique associated with cardiopulmonary resuscitation, as one example.