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  • Dr. Bertha Wu

JOURNAL CLUB - APRIL 2022

Updated: Nov 3, 2023

Journal Club Podcast April 2022

Dr Bertha Wu Prof Peter Cameron Dr Divya Karna

Editor: Dr David McCreary



WELCOME TO THIS MONTH’S JOURNAL CLUB PODCAST. WE ARE JOINED BY PROFESSOR PETER CAMERON, ACADEMIC DIRECTOR FOR THE ALFRED EMERGENCY AND TRAUMA CENTRE, AND DR DIVYA KARNA, EMERGENCY PHYSICIAN.


This month we review 4 papers covering topics of pre-hospital resuscitation of trauma patients with blood products, pad positioning for cardioverting AF, large-bore vs pigtail intercostal catheter use for traumatic haemothorax, and whether pain scores impact the prediction of patient outcome by triage scores.


PAPER 1: RESUSCITATION WITH BLOOD PRODUCTS IN PATIENTS WITH TRAUMA-RELATED HAEMORRHAGIC SHOCK RECEIVING PREHOSPITAL CARE (REPHILL): A MULTICENTRE, OPEN-LABEL, RANDOMIZED CONTROLLED, PHASE 3 TRIAL

READ IT HERE


CLINICAL QUESTION:

Is prehospital administration of packed red cells and lyophilised plasm (LyoPlas) superior to 0.9% in resuscitating patients with trauma-related haemorrhagic shock?


DESIGN

Multicentre, open-label, parallel group, randomized controlled trial, with allocations concealed and primary outcome accessors blinded. The study was performed over 6 years from 2016-2021.


POPULATION

Inclusion:

  • Adults (>16 years)

  • Trauma-related haemorrhagic shock and hypotension (defined as SBP<90mmHg or absent palpable radial pulse)

Exclusion:

  • Patient had already been transfused blood products prior to assessment for eligibility

  • Known refusal to receive blood products

  • Pregnancy (known or apparent)

  • Isolated head injury without evidence of haemorrhage

  • Prisoners

INTERVENTION

Participants receive up to two units each of PRBC and LyoPlas


COMPARISON

Participants receive up to 4 x 250mL bags of 0.9% NaCl


For both groups, the interventions were administered until either hospital arrival, a return of systolic BP to 90mmHg or more, or when a radial pulse was palpable. If BP decreased on the way to hospital, treatment was re-instigated.


OUTCOMES

Composite primary outcome: (powered for 10% difference)

  • Episodic mortality OR

  • Impaired lactate clearance (<20% in 2 hours) OR

  • Both

Secondary outcomes:

  • Rates of transfusion related complication sin the first 24hrs after ED arrival

  • Serious adverse events

  • Treatment-related deaths


FINDINGS

  • Trial recruitment was stopped before it achieved the intended sample size of 490 participants due to disruption caused by the COVID pandemic

  • Only 432 participants were assigned to the PRBC-LyoPlas (n=209) or to the 0.9% sodium chloride group (n=223)

  • The composite primary outcome occurred in 128 (64%) of 199 participants randomly assigned to PRBC-LyoPLas and 136 (65%) of 210 randomly assigned to 0.9% sodium chloride  adjusted risk difference -0.025% with 95% CI -9.0 to 9.0, p = 0.996

  • Rates of transfusion related complication in first 24hrs a