Challenges and Possibilities in Forward Resuscitation

Effect of the implementation of a checklist in the prehospital management of a traumatised patient

Damage control resuscitation (DCR) of the massively bleeding trauma patient comprises early intervention with blood products to replete intravascular volume, restore tissue oxygenation, and correct coagulopathy until surgical hemostasis can be achieved. Blood product resuscitation in the emergency department (ED), and also in the prehospital setting, must be coordinated, prompt, multifaceted, and evidence-based and should incorporate the appropriate use of laboratory tests and adjunct therapies, which facilitate DCR and damage control surgery. Hemostatic resuscitation should also address the management of the acute and delayed complications of massive transfusion including electrolyte imbalances, interstitial edema, acidosis, and hypothermia.

RDCR Symposium fifth-year anniversary edition: global prehospital care rooted in a history of military innovation.

Remote damage control resuscitation is a recently defined term used to describe techniques and strategies to provide hemostatic resuscitation to injured patients in the prehospital setting. In the civilian setting, unlike the typical military setting, patients who require treatment for hemorrhage come in all ages with all types of comorbidities and have bleeding that may be non-trauma related. Thus, in the austere setting, addressing the needs of the patient is no less challenging than in the military environment, albeit the caregivers are typically not putting their lives at risk to provide such care. Two organizations have pioneered remote damage control resuscitation in the civilian environment: Mayo Clinic and Royal Caribbean Cruises Ltd. The limitations in rural Minnesota and shipboard are daunting. Patients who have hemorrhage requiring transfusion are often hundreds of miles from hospitals able to provide damage control resuscitation. This article details the development and implementation of novel programs specifically designed to address the varied needs of patients in such circumstances. The Mayo Clinic program essentially takes a standard-of-care treatment algorithm, by which the patient would be treated in the emergency department or trauma bay, and projects that forward into the rural environment with specially trained prehospital personnel and special resources. Royal Caribbean Cruises Ltd has adapted a traditional military field practice of transfusing warm fresh whole blood, adding significant safety measures not yet reported on the battlefield (see within this Supplement the article entitled "Emergency Whole Blood Use in the Field: A Simplified Protocol for Collection and Transfusion"). The details of development, implementation, and preliminary results of these two civilian programs are described herein.

Damage control resuscitation, avoidance of dilutional coagulopathy, and increased blood component therapy reduce mortality after major trauma hemorrhage. Improved outcomes seen in recent warfare have placed whole blood as the preferred product for resuscitation of severe traumatic hemorrhage. As of 2018, flight physicians of the Israeli Airborne Combat Search and Rescue Unit (ACSRU) treat these patients with low titer cold-stored O-positive whole blood (LTCSO+ WB). Intraosseous (IO) is the preferred route if intravenous access is not available. To date, no study has described the administration of LTCSO+ WB via the IO route in the prehospital setting. We present a case of whole blood transfusion via the IO route in a 30-year-old car accident patient who suffered major injuries and developed severe hemorrhagic shock. Intravenous access could not be obtained at the scene. En route, two units of LTCSO+ WB were administered, using an IO hand drill, and the patient's hemodynamic status improved. The patient survived the injury with a good outcome. This is the first report of whole blood infusion via the IO route in traumatic hemorrhagic shock in the prehospital setting. Our positive experience suggests that this approach may have a role in hemorrhagic trauma patients when intravenous access cannot be obtained.

IntroductionMajor haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase...

Severe traumatic injury is one of the main global health issues which annually causes more than 5.8 million worldwide deaths. Uncontrolled haemorrhage is the main avoidable cause of death among severely injured individuals. Management of trauma patients is the greatest challenge in trauma emergency care, and its proper diagnosis and early management of bleeding trauma patients, including blood transfusion, are critical for patient outcomes. Aim: We aimed to describe the epidemiology of transfusion practices in severe trauma patients admitted into Spanish Intensive Care Units. Material and Methods: We performed a multicenter cross-sectional study in 111 Intensive Care Units across Spain. Adult patients with moderate or severe trauma were eligible. Distribution of frequencies was used for qualitative variables and the mean, with its 95% CI, for quantitative variables. Transfusion programmes, the number of transfusions performed, and the blood component transfused were recorded. Demographic variables, mortality rate, hospital stay, SOFA-score and haemoglobin levels were also gathered. Results: We obtained results from 109 patients. The most transfused blood component was packet red blood cells with 93.8% of total transfusions versus 43.8% of platelets and 37.5% of fresh plasma. The main criteria for transfusion were analytical criteria (43.75%), and acute anaemia with shock (18.75%) and without haemodynamic impact (18.75%). Conclusion: Clinical practice shows a ratio of red blood cells, platelets, and Fresh Frozen Plasma (FFP) of 2:1:1. It is necessary to implement Massive Transfusion Protocols as they appear to improve outcomes. Our study suggests that transfusion of RBC, platelets and FFP in a 2:1:1 ratio could be beneficial for trauma patients.

Death from exsanguinating hemorrhage remains a priority in the management of combat casualties and civilian trauma patients with truncal and junctional injuries. Appropriate use of hemostatic agents and dressings in the prehospital setting may allow for earlier control and an improved survival rate. Third-generation chitosan-based hemostatic agents and dressings appear to be equally efficacious to the dressing currently deployed by the US military forces in the management of hemorrhage not amenable to tourniquet placement. Unfortunately, a lack of clinical trials places a heavy reliance on anecdotal reports and laboratory studies in agent selection and application. Efficacy of currently available hemostatic agents and dressings appears to have plateaued in recent years although new agents and delivery mechanisms under development may improve control in cases of severe hemorrhage.

Background: Hemorrhagic trauma is a major preventable cause of mortality in critically injured patients. Rapid surgical interventions are essential for hemostasis. Comprehensive critical care management before and after surgery significantly enhances the patient survival. Damage control resuscitation (DCR) concept has been adapted from the damage control method of the United States Navy, which outlines immediate temporary measures to prevent a ship from sinking, followed by the definitive repair of the ship at a dock.Current Concepts: DCR combined with damage control surgery focuses on controlling life-threatening hemorrhages and preventing trauma-induced coagulopathy. Key aspects of this strategy are: (1) Permissive hypotension (avoiding excessive fluid resuscitation to reduce re-bleeding risk), (2) restricted fluid and hemostatic resuscitation (limiting fluids and using blood products to promote coagulation), (3) use of antifibrinolytics (administering tranexamic acid to inhibit fibrinolysis and stabilize clots), (4) hypothermia prevention (maintaining normothermia to promote coagulation and mitigate acidosis), (5) calcium maintenance (maintaining normal calcium levels for proper cardiac function and coagulation), and (6) use of vasopressors (for stabilizing blood pressure and tissue perfusion). By integrating these aspects, DCR effectively controls immediate bleeding and overcomes systemic physiological challenges, thereby improving the survival of patients with severe trauma.Discussion and Conclusion: Implementation of DCR with surgical interventions as a bundle of care effectively manages hemorrhagic trauma, possibly saving the patient. Therefore, DCR is a cornerstone strategy to improve the survival of patients with hemorrhagic trauma.

Background Hemorrhagic shock(HS) is one of the major causes of death and disability. Clinical investigation demonstrates that the prognosis of HS patients seems correlated with the strategies applied for resuscitation. However, treatments that can effectively improve the recovery of HS are still absent. Objective To review the treatment of HS with damage control resuscitation(DCR). Content DCR is a new integrated strategy, and has been used in a wide variety of surgeries, including trauma emergency treatment, cardiac surgery, obstetric surgery, etc. HS is commonly seen in patients with trauma-associated coagulopathy, hypothermia, and acidosis, because of the disturbed blood coagulation. DCR recommends permissive hypotension, hemostatic resuscitation, and damage control surgery in the treatment of HS. It not only improves the recovery of HS, but also helps reduce risk of shock-related complications. Trend DCR is a potential treatment for HS, while further investigations are required to optimize the procedures. Key words: Hemorrhagic shock; Damage control resuscitation; Hemostatic resuscitation

Introduction: Major hemorrhage remains a leading cause of preventable death in both civilian and military trauma settings. Tourniquets have emerged as a critical intervention for hemorrhage control; however, their optimal application across various clinical environments requires systematic evaluation. Objective: To systematically review the effectiveness, safety, and clinical outcomes of tourniquet use for major extremity hemorrhage in prehospital and hospital settings. Materials and Methods: We conducted a comprehensive systematic search of PubMed, Scopus, Web of Science, and the Cochrane Library databases for studies published between 2000 and 2024. The inclusion criteria covered randomized controlled trials, cohort studies, and observational studies that assessed the use of tourniquets for major limb hemorrhage. Primary outcomes included survival rates, effectiveness of hemorrhage control, and complication rates. Secondary outcomes included time to hemorrhage control and functional results. Data extraction focused on clinical indications, patient demographics, tourniquet specifications, application timing, and adverse events. Results: Thirty-two studies met the inclusion criteria. Tourniquet use in the prehospital setting was consistently associated with improved survival in patients with severe extremity bleeding, particularly when applied early. Hospital-based tourniquet use has proven effective in surgical or resuscitative contexts but requires careful monitoring to avoid ischemic complications. When used correctly and for limited periods, complication rates remain low. Conclusions: The current evidence strongly supports the use of tourniquets as an effective and safe intervention for major extremity hemorrhage in both prehospital and hospital settings. The early application improves survival outcomes and helps reduce complications. Implementing standardized protocols, comprehensive training programs, and quality improvement initiatives is crucial to maximizing clinical benefits and ensuring patient safety.

Introduction The use of the extremity tourniquet in military environments has reduced preventable deaths due to exsanguinating hemorrhage, leading to increased use in civilian settings. However, the outcomes of contemporary prehospital tourniquet use in civilian settings are not well-described nationally. The objective of this study was to describe the characteristics and outcomes following prehospital tourniquet use by emergency medical services (EMS) in the United States. Methods All trauma activations reported to the National EMS Information System 2019 (NEMSIS) were included. Patients who had ≥1 tourniquet applied were identified. Descriptive analyses were used to compare characteristics between tourniquet and no-tourniquet cohorts. Coarsened exact matching was performed to generate a k2k match (on age, sex, lowest-systolic blood pressure, initial patient acuity, provider’s initial impression, injury mechanism, and presence of upper/lower extremity injuries) and used to compare outcomes. Trauma patients who may have potentially benefited from tourniquet application (extremity injury, shock index ≥1 and no documented tourniquet application) were identified. Results A total of 7,161 tourniquets were applied among 4,571,379 trauma activations (1.6/1000 activations). Patients in the tourniquet cohort were younger (40 ± 18 vs 52 ± 26 mean ± SD years), more hypotensive (16.1% vs. 2.5%) and had higher initial acuity (65.0% critical/emergent vs. 20.6%) [p < 0.01 for all]. A total of 7,074 patients in the tourniquet cohort were matched with 7,074 patients in the non-tourniquet cohort. Post-match analysis revealed that the patients in tourniquet cohort had a higher final acuity (80.8% vs. 75.0%, p < 0.01), lower scene-time (15.4 ± 13.6 vs. 17.0 ± 14.2 mean ± SD minutes, p < 0.01), and higher survival-to-hospital (83.6% vs. 75.1%, p < 0.01). A total of 141,471 trauma patients who may have potentially benefited from tourniquet application were identified. Conclusion Prehospital tourniquet use by EMS in the United States is associated with lower scene-time and improved survivability to hospital. Results indicate that patients might benefit from wider tourniquet use in the civilian prehospital setting.

Uncontrolled hemorrhagic trauma represents a challenge to the intensivist as it is a leading cause of potentially preventable death in trauma patients. Recently, damage control resuscitation and hemostatic resuscitation has become the standard of care for the management of these patients. The aim of this review is to highlight the pathophysiology of acute traumatic coagulopathy and the management of these challenging patients.

Main trauma conference – the first day

Background Thoracic injury directly accounts for 25% of the deaths due to trauma, and is a contributing factor in another 25% of trauma related deaths. As the role of thoracoscopy continues to expand in the practice of thoracic surgery, its role in the management of the trauma patients is also expanding. Objective of the study was to determine the role of emergency VATS in the management of blunt chest trauma patients.