ReviewExsanguination in trauma: A review of diagnostics and treatment options
Introduction
Death due to traumatic injury is the leading cause of life years lost throughout the world.85 Recently, the impact of haemorrhage on trauma outcome has been well-described by Kauvar et al. Haemorrhage is responsible for 30–40% of trauma mortality and of these deaths, 33–56% occur during the prehospital period. Only central nervous system injury, which also has a high rate of prehospital mortality, is consistently more lethal. However, in contrast to haemorrhage and haemorrhagic shock, possibilities for life-saving interventions are very limited in CNS injury. The significant contribution of haemorrhagic shock to brain injury mortality further illustrates the role of haemorrhage control in reducing mortality in trauma patients.66 Haemorrhage accounts for almost 50% of deaths in the first 24 h of trauma care. After day 1, very few haemorrhagic deaths occur. Delayed death in trauma patients is caused by late sequelae as multi-organ failure. The proportion of trauma deaths with multi-organ failure remains unchanged: 7% in the early 1990s and 9% 10 years later.[99], [101], [109] Our paper was written to summarise what is new in the care of the injured concerning the diagnosis and treatment of life-threatening bleeding. An attempt is made to describe the state of the art in managing the exsanguinating trauma patient. New insights, concepts and treatment modalities are discussed as well as potential new therapies for prehospital as well as in-hospital situations.
Section snippets
Concept of prehospital treatment of the bleeding patient
Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs (blood pressure, pulse rate, respiratory rate and if available end tidal carbondioxide) and the patient's response to fluid therapy. Estimations of unknown amounts of blood loss will be inaccurate.84 Shock classifications as proposed by the worldwide-accepted Advanced Trauma Life Support (ATLS®)/Prehospital Trauma Life Support (PHTLS®) guidelines may be
Concept
A well-established communication system between the hospital and the prehospital care providers is essential to prepare for timely, optimal preparation of the receiving team. Within the hospital, sound trauma team activation (TTA) system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. When the responsible (trauma) surgeon is not automatically part of the TTA, triage protocols for TTA should incorporate criteria to call in the
Conclusion
Recognition of traumatic haemorrhage as a treatable ‘disease’ has been well established. The treatment of the patient with exsanguinating injuries has many aspects. Progress has been in many fields regarding early haemorrhage control, resuscitation and coagulation management throughout the last decade and has great potential to improve outcomes in trauma patients. However, as the treatment of these patients (and the interpretation of outcome studies) will always depend on local, regional and
Future directions
As a differentiated approach is warranted, future directions in the treatment of patients with exsanguinating injuries may point in the direction of efforts to improve prehospital care by having experts at the scene, e.g. for critical decision-making. Also, regarding resuscitation, prehospital blood transfusion in cases of stay and play and/or long transport times may be feasible, while awaiting results from oxygen carriers trials. Research has to clarify optimal prehospital fluid resuscitation
Conflict of interest statement
There were no conflicts of interest.
References (125)
- et al.
Treating coagulopathy in trauma patients
Transf Med Rev
(2003) - et al.
Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room
Resuscitation
(2007) Exsanguination from impact head trauma; the explanation for the “empty heart” sign
Forensic Sci Int
(1998)Use of blood transfusions by helicopter emergency medical services: is it safe?
Injury
(1993)- et al.
Blind transfusion of blood products in exsanguinating trauma patients
Resuscitation
(2007) - et al.
The role of recombinant factor VIIa in the treatment of life-threatening haemorrhage in blunt trauma
Injury
(2005) - et al.
Damage control orthopaedics in unstable pelvic ring injuries
Injury
(2004) - et al.
The first randomized trial of human polymerized haemoglobin as a blood substitute in acute trauma and emergent surgery
J Am Coll Surg
(1998) - et al.
The life-sustaining capacity of human polymerized haemoglobin when red cells might be unavailable
J Am Coll Surg
(2002) - et al.
New aspects in the emergency room management of critically injured patients: a multi-slice CT-oriented care algorithm
Injury
(2007)
Emergency thoracotomy in thoracic trauma—a review
Injury
Treatment of traumatic bleeding with recombinant factor VIIa
Lancet
High-pressure fibrin sealant foam: an effective haemostatic agent for treating severe parenchymal haemorrhage
J Surg Res
Diagnostic peritoneal aspiration—the foster child of DPL: a prospective observational study
Int J Surg
The utility of venous lactate to triage injured patients in the trauma center
J Am Coll Surg
The Israeli Multidisciplinary rFVIIa Task Force. Guidelines for the use of recombinant activated factor VII (rFVIIa) in uncontrolled bleeding: a report by the Israeli Multidisciplinary rFVIIa Task Force
J Thromb Haemost
Rescue team. Evaluation of techniques for treating the bleeding wound
Injury
Fluid resuscitation for the trauma patient
Resuscitation
Acute traumatic rupture of the descending thoracic aorta: endovascular treatment
Am J Surg
Advanced trauma life support
Advanced Trauma Life Support (ATLS) program for doctors
MAST-associated compartment syndrome (MACS): a review
J Trauma
Emergency thoracotomy in the pre-hospital setting: a procedure requiring clarification
Eur J Cardiothorac Surg
Institutional practice guidelines on management of pelvic fracture-related haemodynamic instability: do they make a difference?
J Trauma
Prehospital blood transfusion in prolonged evacuation
J Trauma
Sublingual capnometry for rapid determination of the severity of haemorrhagic shock
J Trauma
Basic and advanced prehospital trauma life support
Haemodynamic response to abdominal aortotomy in the anesthetized swine
Circ Shock
Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries
N Engl J Med
Sonography in a clinical algorithm for early evaluation of 1671 patients with blunt abdominal trauma
Am J Roentgenol
NovoSeven Trauma Study Group. Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials
J Trauma
Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway?
Ann Surg
Acute traumatic coagulopathy
J Trauma
Maxillofacial injuries and life-threatening haemorrhage: treatment with transcatheter arterial embolization
J Trauma
Intraosseous infusion devices: a comparison for potential use in special operations
J Trauma
PASG: does it help in the management of traumatic shock?
J Trauma
Improved survival following massive transfusion in patients who have undergone trauma
Arch Surg
Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 min
J Trauma
Antifibrinolytic drugs for acute traumatic injury
Cochrane Database Syst Rev
Early increases in blood lactate following injury
J R Army Med Corps
High-intensity ultrasound treatment of blunt abdominal solid organ injury: an animal model
J Trauma
Preperitonal pelvic packing for haemodynamically unstable pelvic fractures: a paradigm shift
J Trauma
Are automated blood pressure measurements accurate in trauma patients?
J Trauma
Medical anti-shock trousers (pneumatic anti-shock garments) for circulatory support in patients with trauma
Cochrane Database Syst Rev
Hypotensive resuscitation
Shock
Recombinant activated factor VII for trauma patients
Transf Altern Transf Med
Butt binder
J Trauma
European pediatric life support course: EPLS®
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