Damage control resuscitation for patients with bleeding trauma

Exsanguination in trauma: A review of diagnostics and treatment options

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

Damage control: Concept and implementation

War surgery and transfusion in makeshift hospitals in beleaguered cities

Trauma damage control has undergone a recent paradigm shift, broadening its focus from surgery to resuscitation. This review details central components of damage control resuscitation (DCR) across the phases of major injury care and the evidence behind its adoption. Permissive hypotension, minimization of crystalloid fluids, and early balanced blood product resuscitation have each been associated with improved outcomes in hemorrhaging patients. These tactics compliment current strategies of achieving hemorrhage control, including damage control surgery. DCR is now integrated into care from the injury scene, through the resuscitation bay, the operating room, and into the intensive care unit. Its use limits the physiologic derangement experienced by the injured patient and minimizes preventable death from hemorrhage. It has become the accepted standard of modern trauma care and is shaping contemporary trauma systems and education. Future evidence-based advancements in trauma care will be scrutinized against this standard.

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.

The leading cause of preventable death in trauma is uncontrolled bleeding. Some of these deaths may be secondary to the Acute Coagulopathy of Trauma, which is present in 30% of patients on admission to hospital. In recent years, Damage Control Resuscitation has been developed, which aims to give a hemostatic resuscitation and avoid deaths caused by bleeding. This strategy considers control of bleeding with damage control surgery or interventional procedures, early transfusion of all blood products, permissive hypotension and limited use of crystalloids. Several studies have reported that early transfusion of all blood products, with a ratio close to 1:1, may be associated with lower mortality and less requirements of total transfusions in trauma patients at risk of massive bleeding and massive transfusion. These findings must be corroborated in randomized controlled trials, along with determining the optimum ratio between blood products. In stable patients, a restrictive transfusion strategy is safe and appropriate.

This report reviews the recent literature on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the prehospital Tactical Combat Casualty Care (TCCC) environment. A number of changes to the TCCC Guidelines are incorporated: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hextend is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain Tactical Field Care (TFC) settings where this option might be feasible (ships, mounted patrols) is discussed; (4) 1:1:1 damage control resuscitation (DCR) is preferred to 1:1 DCR when platelets are available as well as plasma and red cells; and (5) the 30-minute wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure (BP) has been eliminated. Also included is an order of precedence for resuscitation fluid options. Maintained as recommendations are an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body's hemostatic response and (2) the risk of complications of overresuscitation. Hextend is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.

(iii) An update on the systemic response to trauma

For decades, survival rates of cardiac arrest following trauma were reported between 0 and 2 %. Since 2005, survival rates have increased with awide range up to 39 % and good neurological recovery in every second person injured for unknown reasons. Especially in children, high survival rates with good neurologic outcomes are published. Resuscitation following traumatic cardiac arrest differs significantly from nontraumatic causes. Paramount is treatment of reversible causes, which include massive bleeding, hypoxia, tension pneumothorax, and pericardial tamponade. Treatment of reversible causes should be simultaneous. Chest compression is inferior following traumatic cardiac arrest and should never delay treatment of reversible causes of the traumatic cardiac arrest. In massive bleeding, bleeding control has priority. Damage control resuscitation with permissive hypotension, aggressive coagulation therapy, and damage control surgery represent the pillars of initial treatment. Cardiac arrest due to hypoxia should be resolved by airway management and ventilation. Tension pneumothorax should be decompressed by finger thoracostomy, pericardial tamponade by resuscitative thoracotomy. In addition, resuscitative thoracotomy allows direct and indirect bleeding control. Untreated impact brain apnea may rapidly lead to cardiac arrest and requires quick opening of the airway and effective oxygenation. Established algorithms for treatment of cardiac arrest following trauma enable asafe, structured, and effective management.

Significance: In trauma care, extensive surgical intervention may be required. Damage control surgery (DCS) is applicable to patients with life or limb-threatening conditions that are incapable of tolerating a traditional surgical approach. Recent Advances: The current resuscitation strategy for complex trauma patients includes limiting crystalloid fluids, balanced mass transfusion protocols, permissive hypotension, and damage control resuscitation. Recent technological advancements in surgical critical care have improved outcomes in these critically ill patients. Critical Issues: DCS, which is often required in patients with trauma injuries, is typically followed by surgical correction of the injury once the immediate patient survival procedures have been completed. However, DCS and the subsequent injury repair procedures have a high risk for postsurgical complication development. Future Directions: Negative pressure therapy modalities can offer clinicians additional adjunctive and cost-effective tools for the management of the trauma care patient, as these systems can be utilized during both the DCS and the postoperative injury management phases of trauma care.

Hemostatic Resuscitation in Traumatic Hemorrhagic Shock: Case Report

Trauma hemorrhage continues to carry a high mortality worldwide. The contemporary damage control resuscitation (DCR) paradigm supports actively bleeding trauma patients until hemorrhage control is achieved. The principles of DCR center on early hemorrhage control and limiting ongoing blood loss by adopting strategies limiting fluid administration, reducing blood pressure targets, and maintaining hemostasis through balanced transfusion strategies. Application of DCR strategies has dramatically reduced mortality from trauma hemorrhage and also seems to reduce the incidence and severity of complications such as organ failure and infection. While much of the discussion around DCR focuses on control of coagulopathy and the delivery of a balanced transfusion, the other principles are at least as important. Avoiding clear fluids solutions, especially at the most critical timepoints, require experience and a coordinated, practiced, multidisciplinary approach. The anesthesiologist therefore has a central role to play in the successful delivery of DCR, and perioperative management of fluid administration and the patient’s cardiovascular status can make all the difference between a good and bad outcome. In this article, we discuss the principles of DCR with a focus on areas of trauma anesthesiology management.

Vascular injuries are the leading cause of potentially preventable deaths following penetrating trauma. Damage control principles in the field, the emergency department, and in the operating room play a major role in the salvage of these victims. External bleeding should be controlled by direct digital compression, judicious use of tourniquets, and rapid transportation to a trauma center, especially in an urban environment with short prehospital times. In all cases with suspected vascular injuries, the concept of permissive hypotension has become the new standard. Temporary bleeding control whenever possible, damage control resuscitation, and rapid transportation to the operating room remain the cornerstones of survival in severe vascular injuries. Damage control should be considered in all cases with exhausted physiological reserves at risk of imminent death, in complex injuries requiring special operative skills, in anatomically difficult injuries, in suboptimal environments such as in the battlefield or community hospitals, and if the surgeon is inexperienced with vascular surgery. The surgeon has many damage control technique options in his armamentarium. These techniques include temporary intraluminal shunt insertion, ligation, simple repair, balloon catheter occlusion, and extremity amputation. Running parallel to these efforts is correction of the systemic coagulation defects, by minimizing the use of crystalloid and the early aggressive use of packed red blood cells, plasma, and platelets in a balanced ratio. Complex repairs, such as end-to-end anastomosis or graft interposition should be undertaken at a later stage, after resuscitation and correction of coagulopathy, hypothermia, and acidosis.

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.