John P. Pryor Lecture: Dr. Holcomb discusses how time affects hemorrhagic mortality

John B. Holcomb, MD, FACS
John B. Holcomb, MD, FACS

Representatives of the U.S. military health system met Sunday for the Excelsior Surgical Society meeting, and a highlight of the session was the third annual Army Major John P. Pryor Lecture by guest lecturer John B. Holcomb, MD, FACS, a retired U.S. Army Colonel. Dr. Holcomb was introduced by U.S. Navy CAPT Eric A. Elster, MD, FACS, President of the Excelsior Surgical Society.

Dr. Holcomb began the lecture—The Importance of Time, Anatomy, and Pre-Operating Room (OR) Hemorrhage Hemostatic Interventions: Especially in Patients Requiring Emergent Laparotomy—by reviewing some of the significant figures and publications in the history of battlefield trauma care, including John P. Pryor, MD, FACS, a military surgeon who died in active duty in 2008, before turning to the factors affecting survival of hemorrhagic patients—the most significant being time. “The passage of time is important. Every minute really does count,” said Dr. Holcomb, professor of surgery, McGovern Medical School, University of Texas Health, Houston.

Dr. Holcomb suggested that in most of the places where he and those surgeons in the audience practice, it was difficult to find a “good clock” that starts at the time of injury or admission to the hospital. “We don’t keep track of time, and it is so critically important,” Dr. Holcomb said.

He spoke of the evolving understanding of trauma deaths, from the trimodal distribution based upon the time interval from injury to death (immediate, early, and late) suggested by Donald Trunkey, MD, FACS, in 1983, to the current unimodal distribution that Dr. Holcomb and colleagues have posited in a retrospective study, where the majority of deaths occur within two hours of injury. “From admission, the number of trauma deaths drops almost straight down over three to four hours and levels off,” Dr. Holcomb said.

Trauma deaths occur rapidly and in a consistent pattern, he noted, illustrating the point with the “consistent curve of death,” where every minute that passes up to approximately 200 minutes, hemorrhagic mortality decreases. The data, combined with his experiences in 16 years of war, showed that intervention needs to happen as soon as possible to improve patient outcomes.

Dr. Holcomb pointed to a 2016 study by Ronald M. Stewart, MD, FACS, Chair of the American College of Surgeons Committee on Trauma, and colleagues that reviewed data from 2.5 million truncal hemorrhage patients and showed that median prehospital time was 37 minutes and that the peak times for mortality were the 0 to 15 minutes and 16 to 30 minutes periods. “Our systems are routinely delivering people after the peak time of hemorrhagic death,” said Dr. Holcomb, and suggested that there needs to be a focus on improving interventions in this prehospital period. Such improvements include prehospital whole blood transfusion, increasing training for emergency medical technicians, and new hemostatic technology.

He also explained that the median time from injury to operating room for patients requiring a laparotomy is 87 minutes. “What’s missing from that timeline is the time it takes to stop bleeding,” Dr. Holcomb said. The time spent controlling initial hemorrhage delays the procedure—and since the mortality rate for trauma patients requiring a laparotomy hasn’t changed in the last 20 years despite other advancements, the limiting factor seems to be the lack of prehospital bleeding intervention.

Ultimately, Dr. Holcomb suggested, the solution to decreasing the time from injury to controlling hemorrhage is earlier intervention—in the emergency department or, ideally, before arriving at the hospital. “Time to hemorrhagic death happens at an incredibly consistent, reproducible rate,” Dr. Holcomb said. “I think it’s time to set a pretty audacious goal: to push new interventions to the prehospital setting to stop truncal bleeding.”