Elsevier

Injury

Volume 43, Issue 7, July 2012, Pages 1021-1028
Injury

Review
What's new in resuscitation strategies for the patient with multiple trauma?

https://doi.org/10.1016/j.injury.2012.03.014Get rights and content

Abstract

The last decade has seen a sea change in the management of major haemorrhage following traumatic injury. Damage control resuscitation (DCR), a strategy combining the techniques of permissive hypotension, haemostatic resuscitation and damage control surgery has been widely adopted as the preferred method of resuscitation in patients with haemorrhagic shock. The over-riding goals of DCR are to mitigate metabolic acidosis, hypothermia and coagulopathy and stabilise the patient as early as possible in a critical care setting. This narrative review examines the background to these changes in resuscitation practice, discusses the central importance of traumatic coagulopathy in driving these changes particularly in relation to the use of high FFP:RBC ratio and explores methods of predicting, diagnosing and treating the coagulopathy with massive transfusion protocols as well as newer coagulation factor concentrates. We discuss other areas of trauma haemorrhage management including the role of hypertonic saline and interventional radiology. Throughout this review we specifically examine whether the available evidence supports these newer practices.

Introduction

Worldwide, traumatic injury is the leading cause of mortality in patients under the age of 44,1 and accounts for more than 6 million deaths each year.2 It is estimated that up to 20% of deaths after trauma might be preventable3, 4 and the majority of these are due to uncontrolled haemorrhage. Twenty five percent of all patients admitted to hospital after trauma develop a coagulopathy that further increases their risk of significant haemorrhage.5, 6 Mortality in patients with a coagulopathy, even after adjustment for their injury severity, is 3–4 times higher than patients without coagulopathy.5, 6, 7

The correction and prevention of traumatic coagulopathy has become a central goal of early resuscitation management of haemorrhagic shock following injury. This review will discuss the recent changes in our understanding of traumatic coagulopathy; the importance of the interplay between coagulopathy and resuscitation techniques; and the background behind the recent shift in management of resuscitation towards the early use of red cells and blood products and damage control principles.

Section snippets

Traumatic coagulopathy

Trauma induced coagulopathy describes the hypocoagulable state that occurs after injury and exacerbates bleeding. It is an independent predictor of the need for massive transfusion5, 6 and death,8 and patients who develop a coagulopathy have an increased likelihood of protracted intensive care stay, multi-organ failure (MOF), and specifically renal failure and acute lung injury.7, 9, 10 Traumatic coagulopathy results from many independent but interacting mechanisms; and historically was thought

Damage control resuscitation

There has been a marked shift in the practice of trauma resuscitation over the last decade, towards damage control resuscitation, following data from the military and changes to our understanding of traumatic coagulopathy.52 Damage Control Resuscitation employs multiple approaches to combat acidosis, hypothermia, coagulopathy and hypoperfusion. Techniques include active rewarming, aggressive early blood product administration in an attempt to reverse coagulopathy, enhance clot formation and

Hypertonic saline

The use of hypertonic saline (HTS) is increasing in those with traumatic brain injury (TBI), and is said to have a particularly useful role for the treatment of raised intracranial pressure (ICP) whilst administering small volume fluid resuscitation.99, 100 HTS solutions typically improve cardiovascular output as well as cerebral oxygenation whilst reducing cerebral oedema. In addition it has been reported that HTS may have beneficial effects on modulation of the inflammatory response to trauma

Limitations of this review

This paper was not intended as a systematic review and is therefore open to author bias. The literature around traumatic coagulopathy and major blood loss is limited, and high quality evidence from randomised conttrolled trials and systematic reviews is lacking. The majority of the data reviewed in this article comes from observational studies, and conclusions from these results should be made cautiously. Higher quality evidence has been reviewed thoroughly in two recently published systematic

Conclusion

Mortality in patients with trauma haemorrhage is high, and the last decade has seen a significant shift in resuscitation strategies used to manage severely injured trauma patients. However, the evidence to support such change is limited. In order to move forward large randomised controlled trials and well conducted observational studies with pragmatic endpoints are needed to improve our understanding of the complex interplay between bleeding and resuscitation, traumatic coagulopathy and

Conflict of interest

Both the authors have no conflict of interest to declare.

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