Towards Hemostatic Resuscitation The Changing Understanding of Acute Traumatic Biology, Massive Bleeding, and Damage-Control Resuscitation
Department of Surgery, San Francisco General Hospital and the University of California, San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA 94110, USA. Surgical Clinics of North America
(Impact Factor: 1.88).
08/2012; 92(4):877-91, viii. DOI: 10.1016/j.suc.2012.06.001
During the past decade there has been a profound change in the understanding of postinjury coagulation. Concurrently, new data suggest that a resuscitative strategy to minimize large volumes of crystalloid while recreating whole is associated with reduced morbidity and mortality. This article outlines the history of resuscitation and transfusion practices in trauma, the changing understanding of coagulation and inflammation, and clinical data driving changes in resuscitative conduct. Finally, the current state of the science suggests future basic science and clinical investigation that will drive changes in transfusion and resuscitation in severely injured military personnel and civilian patients.
Available from: Timothy Pohlman
- "During the past decade, the practice of massive transfusion (MT) has expanded appreciably from simply a definition to now a more comprehensive management strategy for hemorrhagic shock referred to as damage control resuscitation (DCR). This new therapeutic paradigm is based on a broader understanding of the pathophysiology of hemorrhagic shock and now integrates advances from multiple disciplines      . Recently, comprehensive transfusion guidelines for management of hemorrhage after injury have been developed in part by the Resuscitation Outcomes Consortium , Trauma Outcomes Group, and the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) studies  , and these guidelines continue to be refined. "
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ABSTRACT: The early recognition and management of hemorrhage shock are among the most difficult tasks challenging the clinician during primary assessment of the acutely bleeding patient. Often with little time, within a chaotic setting, and without sufficient clinical data, a decision must be reached to begin transfusion of blood components in massive amounts. The practice of massive transfusion has advanced considerably and is now a more complete and, arguably, more effective process. This new therapeutic paradigm, referred to as damage control resuscitation (DCR), differs considerably in many important respects from previous management strategies for catastrophic blood loss. We review several important elements of DCR including immediate correction of specific coagulopathies induced by hemorrhage and management of several extreme homeostatic imbalances that may appear in the aftermath of resuscitation. We also emphasize that the foremost objective in managing exsanguinating hemorrhage is always expedient and definitive control of the source of bleeding.
Copyright © 2015. Published by Elsevier Ltd.
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Damage control laparotomy (DCL) and the open abdomen have been well accepted following either severe abdominal trauma or emergency surgical disease. As DCL is increasingly utilized as a therapeutic option, appropriate management of the post-DCL patient is important. Early caloric support by enteral nutrition (EN) in the critically ill patient improves wound healing and decreases septic complications, lung injury, and multi-system organ failure. However, following DCL, nutritional strategies can be challenging and, at times, even daunting.
Even though limited data exist, the use of early EN following DCL seems safe, provided that the patient is not undergoing active resuscitation or the bowel is not in discontinuity. It is unknown as to whether EN in the open abdomen reduces septic complications, prevents enterocutaneous fistula (ECF), or alters the timing of definitive abdominal wall closure. Future investigation in a prospective manner may help elucidate these important questions.
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