Elsevier

Injury

Volume 40, Issue 1, January 2009, Pages 11-20
Injury

Review
Exsanguination in trauma: A review of diagnostics and treatment options

https://doi.org/10.1016/j.injury.2008.10.007Get rights and content

Abstract

Trauma patients with haemorrhagic shock who only transiently respond or do not respond to fluid therapy and/or the administration of blood products have exsanguinating injuries. Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs and the therapeutic response of the patient. The aim of prehospital care of bleeding trauma patients is to deliver the patient to a facility for definitive care within the shortest amount of time by rapid transport and minimise therapy to what is necessary to maintain adequate vital signs. Rapid decisions have to be made using regional trauma triage protocols that have incorporated patient condition, transport times and the level of care than can be performed by the prehospital care providers and the receiving hospitals. The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. To prevent further deterioration and subsequent exsanguinations ‘permissive hypotension’ may be the goal to achieve. Within the hospital, a sound trauma team activation system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma. Abdominal ultrasound has replaced diagnostic peritoneal lavage for detection of haemoperitoneum. With the development of sliding-gantry based computer tomography diagnostic systems, rapid evaluation by CT-scanning of the trauma patient is possible during resuscitation. The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance in the treatment of exsanguinating trauma patients and is adopted worldwide. When performing ‘blind’ transfusion or ‘damage control resuscitation’, a predetermined fixed ratio of blood components may result in the administration of higher plasma and platelets doses and may improve outcome. The role of thromboelastography and thromboelastometry as point-of-care tests for coagulation in massive blood loss is emerging, providing information about actual clot formation and clot stability, shortly (10 min) after the blood sample is taken. Thus, therapy guided by the test results will allow for administration of specific coagulation factors that will be depleted despite administration with fresh frozen plasma during massive transfusion of blood components.

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.

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