ArticlePDF AvailableLiterature Review

Early fluid resuscitation in severe trauma

  • Hywel Dda University Health Board


#### Summary points Trauma is a global health problem that affects patients in both rich and poor countries and accounts for 10 000 deaths each day.1 2 Trauma is the second leading cause of death after HIV/AIDS in the 5-45 year old age group.w1 w2 Early triage and resuscitation decisions affect outcome in trauma situations.w3 w4 The two leading causes of mortality in trauma are neurological injury and blood loss.3 4 w5 w6 There has been considerable improvement in our understanding of trauma resuscitation in the past 20 years, and data from databases and observational trials suggests outcomes are improving.w7 For patients with severe traumatic injuries (defined as <15 by the injury severity score, an anatomical scoring system), the high volume fluid resuscitation promoted by early advanced trauma life support manuals,5 followed by definitive surgical care, has given way to a damage …
38 BMJ | 15 SEPTEMBER 2012 | VOLUME 345
of patients; however, physician decision and experience have
been found to be just as accurate.w9 w10 w11 w12 w13 Failure to
identify these patients early and to apply DCR is associated
with excess mortality.8
How can trauma patients in shock be identified?
Shock may be dened as a life threatening condition char-
acterised by inadequate delivery of oxygen to vital organs in
relation to their metabolic requirements.9 A systolic blood
pressure of 90 mm Hg is commonly used to dene both
hypotension and shock; however, oxygen delivery depends
on cardiac output rather than blood pressure. Homeostasis
with peripheral vasoconstriction acts to preserve blood pres-
sure even as circulating volume is lost. In patients who have
had trauma, adequate cardiac output cannot be inferred
from blood pressure. Only when blood loss approaches half
the circulating volume or occurs rapidly is there a relation
between the cardiac output and blood pressure.
presenting with hypotension, tachycardia, and obvious
blood loss are readily identied as being in a state of haem-
orrhagic shock. However, many patients will maintain their
pulse and blood pressure even aer massive blood loss and
tissue hypoxia. This condition is termed cryptic shock and
is associated with increased mortality.w14
The role of basic physiological parameters to estimate the
severity of blood loss has been popularised in the advanced
trauma life support courses and manuals.5 These materi-
als describe physiological deterioration with increasing
Trauma is a global health problem that aects patients
in both rich and poor countries and accounts for 10 000
deaths each day.1 2 Trauma is the second leading cause of
death aer HIV/AIDS in the 5-45 year old age group.w1 w2
Early triage and resuscitation decisions aect outcome in
trauma situations.w3 w4 The two leading causes of mortality
in trauma are neurological injury and blood loss.3 4 w5 w6
There has been considerable improvement in our under-
standing of trauma resuscitation in the past 20 years, and
data from databases and observational trials suggests out-
comes are improving.
For patients with severe traumatic
injuries (dened as <15 by the injury severity score, an
anatomical scoring system), the high volume uid resus-
citation promoted by early advanced trauma life support
followed by denitive surgical care, has given
way to a damage control resuscitation (DCR) strategy (box).
This DCR approach has seen a fall in the volume of
crystalloid delivered in the emergency department and an
associated fall in mortality.6 w8 In this review, we summa-
rise the evidence guiding the initial period of resuscitation
from arrival in the emergency department to transfer to
intensive care or operating theatre, focusing on trauma
in critically injured adults. This article emphasises newer
developments in trauma care. There is debate on whether
patients with brain injury should be resuscitated to higher
blood pressures, which is briey discussed later in the text.
How can patients who need DCR be identified?
A DCR strategy applies to patients who present with sus-
pected major haemorrhage. While many denitions exist,
the most practical in the acute trauma setting is for estimated
blood transfusion volumes of over four units in the initial 2-4
h. Identifying these patients can be a challenge because they
are oen young with good physiological reserve and may
have no physiological evidence of hypovolaemic shock.7 A
number of tools have been developed to identify this group
1Barts and the London School of
Medicine and Dentistry, Queen
Mary University of London,
London, UK
2Barts Health NHS Trust, London
316 Air Assault Medical Regiment
4Royal London and Queen Victoria,
East Grinstead, UK
Correspondence to
: T Harris,
Department of Emergency
Medicine, Royal London Hospital,
Whitechapel, London E11BB
Cite this as: BMJ 2012;345:e5752
doi: 10.1136/bmj.e5752
Early fluid resuscitation in severe trauma
Tim Harris,1 2 G O Rhys Thomas,3 4 2 Karim Brohi1 2
Critically injured trauma patients may have normal cardiovascular and respiratory
parameters (pulse, blood pressure, respiratory rate), and no single physiological or
metabolic factor accurately identifies all patients in this group
Initial resuscitation for severely injured patients is based on a strategy of permissive
hypovolaemia (hypotension) (that is, fluid resuscitation delivered to increase blood
pressure without reaching normotension, aiming for cerebration in the awake patient, or
70-80 mm Hg in penetrating trauma and 90 mm Hg in blunt trauma) and blood product
based resuscitation
This period of hypovolaemia (hypotension) should be kept to a minimum, with rapid
transfer to the operating theatre for definitive care
Crystalloid or colloid based resuscitation in severely injured patients is associated with
worse outcome
Once haemostasis has been achieved, resuscitation targeted to measures of cardiac output
or oxygen delivery or use improves outcome
Tranexamic acid administered intravenously within 3 h of injury improves mortality in patients
who are thought to be bleeding
ollow the link from the
online version of this ar
o obtain certied continuing
al education credits
Permissive hypovolaemia (hypotension) (see summary
Haemostatic transfusion (resuscitation)—that is, fresh
frozen plasma, platelets, or packed red blood cells,
and tranexamic acid. Avoidance of crystalloids (normal
saline, Hartmann’s, Ringer’s lactate solutions), colloids (a
substance microscopically dispersed evenly throughout
another substance; with resuscitation fluids, this term
refers to larger molecules dispersed most usually in normal
saline, such as gelofusion, haemaccel, or volulyte), and
Damage control surgery or angiography to treat the cause
of bleeding
Restore organ perfusion and oxygen delivery with definitive
We searched Medline, Embase, the Cochrane database,
and Google for randomised controlled trials, meta-analyses,
and peer reviewed articles, limiting the search to adults.
The search was performed once by the lead author (TH) and
once by a professional librarian. All articles were shared
and supplemented by the author’s own libraries. The
main search terms used were “trauma,” “resuscitation,”
“fluid,” and “goal directed therapy.” Ongoing studies were
identified from
BMJ | 15 SEPTEMBER 2012 | VOLUME 345 39
volumes of blood loss, and categorise four stages of shock.
But data from a 1989-2007 analysis of the United Kingdom
Trauma Audit Research Network database suggest that this
model is not reected in practice. Patients with progressive
levels of blood loss to stage 4 haemorrhagic shock (equating
to >2 L blood loss) were found to increase their pulse rates
from 82 to 95 beats per minute, not to change respiratory
rates or Glasgow coma scale, and maintain systolic blood
pressures above 120 mm Hg.11 Although an important part
of the initial assessment, physiological derangement alone
is neither sensitive nor specic as a tool to identify shock in
trauma patients.7
There is observational evidence from large datasets in
the UK and United States that mortality increases in trauma
patients in both blunt and penetrating trauma, while s ystolic
blood pressure falls below 110 mm Hg.12 w15 w16 w17 w18 w19 A
US review of 870 634 sets of trauma records identied that
for every 10 mm Hg below 110 mm Hg, mortality increased
by 4.8%.
Shock index does not improve aer risk stratica-
tion of trauma patients.w20
Metabolic assessment with lactatew21 w22 and base
excessw23 w24 also predicts blood loss and mortality. Fur-
thermore, these parameters may be increased from exer-
cise around the time of injury (running, ghting) or may be
(falsely) low if the hypoxic tissues are not being perfused
suciently to wash anaerobic products into the circulation
(for example, when a tourniquet is applied). For patients
in whom central access is obtained, mixed venous oxygen
saturation is also a good indicator of blood loss, with levels
below 70% suggesting inadequate oxygen delivery.w25
Estimated injuries and associated blood loss are an import-
ant part of the initial trauma assessment. Clinical examina-
tion is augmented by focused ultrasound assessment of the
chest, pericardium, and peritoneal cavity (extended focused
assessment with sonography in trauma (eFAST), a specic
but insensitive test for blood loss); and computed tomo-
graphy (a sensitive and specic test for blood loss).
What is permissive hypotension (hypovolaemic)
Permissive (hypotension) hypovolaemic resuscitation is
used to describe a process that minimises administration
of uid resuscitation until haemorrhage control has been
achieved, or is deemed unnecessary on denitive imaging.
Resuscitation is the restoration of oxygen delivery and organ
perfusion to match requirements. In the 1960s and 1970s,
a strategy of high volume crystalloid resuscitation in a ratio
of 3 mL per 1 mL of blood loss was promoted, which was
thought to replace intravascular and interstitial losses and
reduce the risk of organ failure.13 However, vigorous uid
resuscitation increases blood pressure, the eect of which
increases hydrostatic forces on newly formed clot, dilutes
clotting factors and haemoglobin, and reduces body temper-
ature. These eects could promote further bleeding. In per-
missive hypotension, denitive resuscitation is deferred until
haemostasis is obtained. It is now recognised that aggressive
crystalloid resuscitation also impairs organ perfusion.14 w26
What evidence do we have for hypovolaemic
Considerable animal work has informed our understanding
of hypovolaemic resuscitation. In summary, this research
found that withholding uid resuscitation from animals
with critical blood loss (about half their circulating vol-
ume) was associated with death, whereas animals with
less severe blood loss had a lower mortality with no uid
The table summarises three randomised controlled trials
exploring the risks and benets of hypovolaemic resusci-
tation.16 17 w27 These trials provide evidence of a mortality
advantage in favour of this resuscitation strategy for trun-
cal penetrating trauma and evidence of no harm in blunt
The National Institute for Health and Clinical Excellence
has recommended that in older children and adults with
blunt trauma, no uid be administered in the prehospi-
tal resuscitation phase if a radial pulse can be felt, or for
penetrating trauma if a central pulse is palpable.18 In the
absence of this, 250 mL crystalloid uid boluses are admin-
istered and the patient is reassessed until these pulses, as
described, return.
Much of the evidence for hypovolaemic resuscitation was
developed before the advent of haemostatic resuscitation,
as described below. This period of hypovolaemic resuscita-
tion is maintained for as short a period as possible, until the
injury complex is dened and any sites of blood loss treated
surgically or embolised.
Untreated hypovolaemic shock leads to microvascular
hypoperfusion and hypoxia, leading to multiorgan failure.19
Hypovolaemic resuscitation sacrices perfusion for coagula-
tion and haemorrhage control. The trauma team carefully
balances the resuscitation process to maintain organ per-
fusion but at lower than normal blood pressure to regulate
bleeding. Based on the evidence available, we suggest that
uid resuscitation before haemorrhage control should aim
to maintain a systolic blood pressure of 80 mm Hg or a
Randomised trials of permissive hypotension in trauma
Trial Intervention Patient group Setting Findings Comments
controlled trial16
No fluid resuscitation before
surgical intervention in
operating theatre v crystalloid
based resuscitation
Penetrating truncal trauma and
systolic blood pressure >90 mm
Hg (n=598)
Prehospital and
in emergency
Lower mortality in group with no
fluid resuscitation than in group
with crystalloid based resuscitation
(survival 70% v 62%, P=0.04)
Short transport distances, mortality
benefit predominantly vascular injuries,
young cohort (mean age 31 years), 8% in
no fluid group received fluids
Randomised controlled
Resuscitation to target systolic
blood pressure 100 mm Hg v
70 mm Hg
Blunt or penetrating trauma and
systolic blood pressure <90 mm
Hg in first hour (n=110)
Urban trauma centre
resuscitation room
No mortality difference, low
mortality of four (7.3%) patients in
each group
Low mortality, study underpowered to
show mortality difference, observed
systolic blood pressures were 114 mm
Hg and 100 mm Hg despite targets
Randomised controlled
trial: interim analysisw27
Intraoperative resuscitation to
mean arterial pressure 50 mm
Hg v 65 mm Hg
Traumatic injuries excluding
traumatic brain injury with at least
one episode of systolic blood
pressure <90 mm Hg (n=90)
Operating theatre No mortality difference Observed blood pressures did not differ
significantly despite targets; results may
not translate to preoperative environment
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40 BMJ | 15 SEPTEMBER 2012 | VOLUME 345
p alpable radial pulse or cerebration by using small volume
boluses of 250 mL. This value is arbitrary with little evidence
to support it. The 250 mL boluses are able to increase blood
pressure, since the circulation is highly constricted with a
small volume of distribution. In practice, achieving target
blood pressures is challenging. Patients with severe injuries
will probably need blood product based resuscitation, as
described below.
Fluid resuscitation in traumatic brain injury
This review does not deal in detail with the complexities
of resuscitation in brain injury; however, retrospective
observational data for patients with traumatic brain injury
suggest that any single reduction in mean arterial blood
pressure below 90 mm Hg is associated with a doubling in
w28 w29
Guidelines published by the Brain Trauma
Foundation advocate maintaining a systolic blood pressure
above 90 mm Hg but do not specically state whether this is
during active haemorrhage.w30 Currently, there is controversy
about whether the guidelines for permissive hypotension
should be changed in the presence of head injury because
there is no human evidence from prospective studies.
What is the role of blood products in trauma resuscitation?
Severe bleeding in trauma patients can result in disordered
blood clotting. Until recently, this eect was thought to be
a late phenomenon arising primarily from loss of coagula-
tion factors during haemorrhage and dilution from resus-
citation uids. However, it is now recognised that trauma
induced coagulopathy occurs within minutes of injury, and
is as sociated with a fourfold increase in mortality.20 The
process is multifactorial21 but is partly due to an endogenous
coagulo pathy that occurs as a result of tissue damage in
severe shock.w31 This understanding has led to changes in
the management of trauma haemorrhage.
Haemostatic resuscitation
Haemostatic resuscitation is a combination of strategies
targeting trauma induced coagulopathy to reduce bleeding
and improve outcomes.w32 w33
How do blood products aid in resuscitation?
The main strategy to treat trauma induced coagulopathy is
to provide volume replacement that augments coagulation.
This replacement has been achieved by the transfusion of
fresh frozen plasma, platelets, and packed red blood cells.
A retrospective observational study performed on military
personnel with similar injuries but diering resuscitation
uid strategies suggested that the use of higher ratios of
fresh frozen plasma to packed red blood cells may improve
outcomes.22 Similar results have been seen in other ret-
rospective studies and a few small prospective cohort
although the retrospective studies are subject to
survival bias.
It is also unclear whether the benet from these strate-
gies comes from the coagulation factors present in fresh
frozen plasma or from reducing the amount of crystalloid
and colloid administered. Nevertheless, it seems clear that
the usual 1-2 units of plasma previously administered aer
massive transfusions was insucient to prevent dilutional
coagulopathy. Current consensus is that plasma should be
given from the beginning of the resuscitation, alongside
transfusions of packed red blood cells, in a ratio of 1 “unit”
of plasma for each 1-2 units of packed red blood cells.24
Very little is known about platelet function in trauma
induced coagulopathy or the effectiveness of platelet
transfusions.w34 w35 Although these early strategies of blood
product in high doses seem eective, they are based on
limited evidence. These regimens also place substantial
resource demands on blood banks and are logistically dif-
cult to implement owing to the requirements for rapid
thawing and delivery.
Research is also being undertaken to look at alterna-
tives to blood component therapy for the management
of trauma induced coagulopathy. Fibrinogen is the cen-
tral substrate of blood clotting, and levels are low in this
patient group.
Some retrospective evidence suggests
that patients who receive more brinogen replacement
(in the form of cryoprecipitate and plasma) have bet-
ter outcomes in terms of total use of packed red blood
cells and mortality.w37 Fibrinogen is also available as a
powdered concentrate and could be a replacement ther-
apy that can be easily administered in trauma induced
coagulopathy.w38 w39
Resources for healthcare professionals (—an independent, non-profit organisation providing global
education and information for professionals involved in trauma care
Eastern Association for Surgery of Trauma guidelines (
guideline)—provides a series of evidence based guidelines for trauma care
Online lectures from massive transfusion and coagulopathy state of the art symposium at the
London Trauma Conference in 2008 (—provides a
series of lectures on blood transfusion, resuscitation, and trauma induced coagulopathy
Resources for patients website (—UK patient website providing wide range of
information and discussing a variety of injuries
Cohen D. Code red: repairing blood in the emergency room. New Scientist 2011. www.
Trauma information pages (—provides simply worded information
specifically for non-healthcare professionals concerning traumatic injuries
National Institute of Neurological Disorders and Stroke. Information page on traumatic
brain injury. 2012.—provides clearly written
information directed at members of the public and healthcare professionals on a variety of
neurological insults, including traumatic brain injuries
PROPPR (pragmatic, randomised optional platelets and plasma ratios): randomised controlled
trial of 1:1:1 v 1:1:2 of red blood cells to platelets to plasma in patients requiring massive
transfusion, seeking to better define the ratio of plasma to packed red blood cells for damage
control resuscitation (NCT01545232)
MP4OX phase IIb trial for ischaemia rescue (lactate clearance): trial exploring the use of an
oxygen carrying colloid in trauma resuscitation (NCT01262196)
VITRIS (vasopressin for therapy of persistent traumatic hemorrhagic shock): multicentre
randomised controlled trial further exploring the role of vasopressin in fluid resistant shock
CIST (colloids in severe trauma): multicentre pilot study of volume resuscitation based on
crystalloid only versus crystalloid-colloid (starch based) in trauma; this randomised controlled
trial has just been completed, looking particularly at the incidence of intra-abdominal
hypertension (NCT00890383)
HypoResus (field trial of hypotensive v standard resuscitation for hemorrhagic shock after
trauma): randomised controlled trial comparing standard resuscitation with hypotensive
resuscitation prehospital and in the first 2 h in the emergency department (NCT01411852)
BMJ | 15 SEPTEMBER 2012 | VOLUME 345 41
controlled trial of 229 patients with hypotension and severe
traumatic brain injury (Glasgow coma scale <9) who received
prehospital resuscitation with hypertonic or normal saline
had almost identical survival and neurological function six
months aer injury.28 Furthermore, a recent randomised con-
trolled trial of prehospital use of hypertonic solutions was
terminated by the data and safety monitoring board aer ran-
domisation of 1331 patients, having met prespecied futility
criteria. Among patients with severe traumatic brain injury
not in hypovolaemic shock, initial resuscitation with either
hypertonic saline or hypertonic saline or dextran, compared
with normal saline, did not result in improved neurological
outcome or survival at six months.29 Thus, we suggest the
use of crystalloid based uid administration in this cohort
of patients who are less severely injured.
Once haemostasis is achieved, what should be done to
ensure adequate resuscitation in severe trauma?
Once haemostasis has been achieved with surgical inter-
vention, fracture splintage or angiography, or the require-
ment for these interventions identied as not necessary,
then denitive resuscitation is required. If patients are
resuscitated to normal blood pressure and pulse with-
out further parameters being used to evaluate for tissue
hypoxia, over half of patients would be inadequately
resuscitated, with increased morbidity and mortality.30 w42
Resuscitation to targets of oxygen delivery or use is termed
goal directed therapy, and good quality evidence from ran-
domised trials indicates that this approach should be used
in trauma; indeed, the original evidence for this approach
came from trauma studies.w43 w44 w45 w46 w47 31 32
What other agents should be used in the initial
resuscitation period?
Hyperbrinolysis is common aer trauma, owing to associ-
ated hypovolaemic shock and tissue injury.w48 In a recent,
large, multinational randomised controlled trial research-
ers targeted a specic component of trauma induced coag-
ulopathy—hyperbrinolysis. They showed a reduction in
mortality with the use of tranexamic acid, which has anti-
brinolytic properties (1 g delivered over 15 min, then 1 g
over 4 h, commenced within 3 h of injury).33
: TH conceived the review and wrote the introduction,
sections of permissive hypovolaemia, resuscitation endpoints, and fluid
resuscitation. RT wrote the sections contrasting colloids and crystalloids
with hypertonic saline. KB wrote the sections on blood product use and
trauma induced coagulopathy. The contributions were correlated by TH,
and all authors reviewed the paper. TH is guarantor.
Competing interests
: KB has received unrestricted research funding from
Octapharma and Thromboelastometry and has consulted for Haemonetics
and Sangart; no other relationships or activities that could appear to have
influenced the submitted work.
Provenance and peer review
: Commissioned; externally peer reviewed.
1 Roberts I, Shakur H, Edwards P, Yates D, Sandercock P. Trauma care research
and the war on uncertainty. BMJ 2005;331:1094-6.
2 Kauvar DS, Lefering R, Wade CE. Impact of haemorrhage on trauma outcome:
an overview of epidemiology, clinical presentations and therapeutic
considerations. J Trauma 2006;60:S3-11.
3 Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM,
et al. The role of secondary brain injury in determining outcome from severe
head injury. J Trauma 1993;34:216-22.
4 Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl
R, et al. Guidelines for the management of severe traumatic brain injury. I.
Blood pressure and oxygenation. J Neurotrauma 2007;24(suppl 1):S7-13.
How do I identify patients with trauma induced coagulopathy?
Standard clotting tests from laboratories such as the pro-
thrombin time do not show any of the key derangements in
trauma induced coagulopathy, such as reduced clot strength
and brinolysis.25 Furthermore, in a trauma setting, it is
impractical to wait for tests that can take up 1 h to process.
The point of care versions of these tests (such as the pro-
thrombin time) are prone to be under-read in the presence
of low haematocrits. These diculties have led to a renewed
interest in the use of thromboelastography—a point of care
assessment of clot generation, strength, and breakdown.
This procedure has the potential to provide a rapid assess-
ment of the whole clotting process, but it has not yet been
validated in the acute setting.25 In the absence of a validated
diagnostic test at the point of care, management is therefore
blind to the status of the coagulation system and relies on
clinical judgment and empiric therapy.
What fluids should be used to resuscitate trauma patients
who do not need DCR?
Patients who do not need DCR need no immediate resuscita-
tion until denitive imaging has identied the underlying
injuries. These patients should be observed carefully for signs
of physiological and metabolic deterioration, consequent
on disease progression with blood loss, visceral injury, and
pericardial or pleural tamponade. Debate continues on the
relative merits of colloid or crystalloid based resuscitation
strategies, with a recent Cochrane review concluding that
there was no evidence that survival was better with one or
the other solution.26
However, a subgroup analysis of 460 patients with trau-
matic brain injury (Glasgow coma scale ≤13) from a large ran-
domised controlled trial comparing the safety of albumin in
normal saline with normal saline identied a survival advan-
tage in the crystalloid group (33.2% v 20.4%, P=0.003).27
Hypertonic solutions have been proposed to improve cer-
ebral perfusion and reduce cerebral oedema, and have been
advocated for resuscitation of patients with traumatic brain
A meta-analysis of eight randomised trials identi-
ed a survival advantage in this group,w41 but a randomised
Doctors and nurses who care for trauma patients who are severely injured need to be
familiar with the principles of resuscitation strategies for damage control, as outlined in this
A clearly written protocol for massive transfusion facilitates rapid access to and delivery of
blood product based resuscitation
Transfer patients with severe traumatic injuries to a dedicated trauma unit
Trauma teams bring together doctors and nurses from a range of disciplines, and scenario
based practice is likely to facilitate smooth teamwork
How do we balance the risks of impaired organ perfusion consequent on hypovolaemic
resuscitation with clot preservation?
How do we identify and target trauma induced coagulopathy in the acute phase?
What is the most effective combination of blood products for initial trauma resuscitation?
Should patients with traumatic brain injury be subject to different initial resuscitation
Does therapeutic hypothermia have a role in trauma resuscitation or traumatic brain injury
in the acute phase?
42 BMJ | 15 SEPTEMBER 2012 | VOLUME 345
21 Hess JR, Brohi K, Dutton RP, Hauser CJ, Holcomb JB, Kluger Y, et al. The
coagulopathy of trauma: a review of mechanisms. J Trauma 2008;65:
22 Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC,
et al. The ratio of blood products transfused affects mortality in patients
receiving massive transfusions at a combat support hospital. J Trauma
23 Rajasekhar A, Gowing R, Zarychanski R, Arnold DM, Lim W, Crowther MA,
et al. Survival of trauma patients after massive red blood cell transfusion
using a high or low red blood cell to plasma transfusion ratio. Crit Care Med
24 Davenport R, Curry N, Manson J, De’Ath H, Coates A, Rourke C, et al.
Hemostatic effects of fresh frozen plasma may be maximal at red cell ratios
of 1:2. J Trauma 2011;70:90-5.
25 Davenport R, Manson J, De’Ath H, Platton S, Coates A, Allard S, et al.
Functional definition and characterization of acute traumatic coagulopathy.
Crit Care Med 2011;39:2652-8.
26 Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in
critically ill patients. Cochrane Database Syst Rev 2011;3:CD000567.
27 SAFE Study Investigators; Australian and New Zealand Intensive Care Society
Clinical Trials Group; Australian Red Cross Blood Service; George Institute
for International Health, Myburgh J, Cooper DJ, et al. Saline or albumin
for fluid resuscitation in patients with traumatic brain injury. N Engl J Med
28 Cooper JD, Myles PS, McDermott FT, Murray LJ, Laidlaw J, Cooper G, et al.
Pre-hospital hypertonic saline resuscitation of patients with hypotension
and severe traumatic brain injury: a randomized controlled trial. JAMA
29 Bulger EM, May S. Out-of-hospital hypertonic resuscitation following severe
traumatic brain injury: a randomized controlled trial. JAMA 2010;304:
30 Claridge JA, Crabtree TD, Pelletier SJ, Butler K, Sawyer RG, Young JS. Persistent
occult hypoperfusion is associated with a significant infection rate and
mortality in major trauma patients. J Trauma 2000;48:8-13.
31 McKinley BA, Valdivia A, Moore FA. Goal-orientated shock resuscitation
for major torso trauma: what are we learning? Curr Opin Critical Care
32 Chytra I, Pradl R, Bosman R, Pelnár P, Kasal E, Zidková A. Esophageal Doppler-
guided fluid management decreases blood lactate levels in multiple-trauma
patients: a randomized controlled trial. Critical Care 2007;11:R24.
33 CRASH-2 Collaborators, Shakur H, Roberts I, Bautista R, Caballero J, Coats
T, et al. Effects of tranexamic acid on death, vascular occlusive events, and
blood transfusion in trauma patients with significant haemorrhage (CRASH-2):
a randomised, placebo-controlled trial. Lancet 2010;376:23-32.
5 American College of Surgeons Committee on Trauma. Advanced trauma life
support for doctors. American College of Surgeons Committee on Trauma,
6 Ley EJ, Clond MA, Srour MK, Barnajian M, Mirocha J, Margulies DR, et
al. Emergency department crystalloid resuscitation of 1.5 L or more is
associated with increased mortality in elderly and nonelderly trauma
patients. J Trauma 2011;70:398-400.
7 Stanworth SJ, Morris TP, Gaarder C, Goslings JC, Maegele M, Cohen MJ, et al.
Reappraising the concept of massive transfusion in trauma. Crit Care Med
8 Larson CR, White CE, Spinella PC, Jones JA, Holcomb JB, Blackbourne LH, et
al. Association of shock, coagulopathy, and initial vital signs with massive
transfusion in combat casualties. J Trauma 2010;69:S26-32.
9 Strehlow MC. Early identification of shock in critically ill patients. Emerg Med
Clin N Am 2010;28:57-66.
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of blood pressure and heart rate to evaluate cardiac output in emergency
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estimated blood loss in patients with major trauma: testing the validity of the
ATLS classification of hypovolaemic shock. Resuscitation 2011;82:556-9.
12 Eastridge BJ, Salinas J, McManus JG, Blackburn L, Bugler EM, Cooke WH, et
al. Hypotension begins at 110 mm Hg: redefining ‘hypotension’ with data. J
Trauma 2007;63:291-9.
13 Shires GT, Canizaro PC. Fluid resuscitation in the severely injured. Clin Surg N
Am 1973;53:1341-66.
14 Cotton BA, Guy JS, Morris JA Jr, Abumrad NN. The cellular, metabolic, and
systemic consequences of aggressive fluid resuscitation strategies. Shock
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Immediate versus delayed fluid resuscitation for hypotensive patients with
penetrating torso injuries. N Engl J Med 1994;331:1105-9.
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18 National Institute for Health and Clinical Excellence. Pre-hospital initiation
of fluid replacement therapy in trauma. Technology appraisal 74. January
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coagulopathy in trauma patients: an on-scene and hospital admission study.
Injury 2012;43:26-32.
For long answers go to the Education channel on
Ear pain and facial palsy
1 Necrotising (malignant) otitis externa.
2 The House-Brackmann grading system.
3 Admission for intravenous antibiotics, aural microsuction, eye care, pain management, and
occasionally surgical debridement.
Hazards and hazard ratios
Statements a and d are true, whereas b
and c are false.
Echocardiogram showing evidence of a
pericardial effusion (white arrow)
Signs of shock and raised jugular venous pressure
1 The chest radiograph shows a globular cardiac silhouette, possibly as a result of fluid
surrounding the heart. The echocardiogram shows a large pericardial effusion (figure).
2 Cardiac tamponade. Electrocardiography classically shows diffuse decreased QRS voltages and
may display electrical alternans.
3 In view of the slow onset, associated weight loss, and other systemic symptoms, cancer is the
most likely diagnosis. In developing countries tuberculosis should also be considered.
4 Beck’s triad and Kussmaul’s sign were seen in this patient. Pulsus paradoxus could be
looked for.
5 Urgent pericardiocentesis under fluoroscopy or echocardiographic guidance should be
undertaken. Fluid should be sent for cytology, protein count, and microbiology. The underlying
cause of the tamponade will need appropriate management.
... Current therapeutic strategies for trauma patients focus on hemostatic resuscitation, with permissive hypovolemia and blood productbased resuscitation, followed by definitive hemorrhage control before definitive restoration of circulating volume and tissue perfusion [3][4][5]. The low blood flow induced by trauma and hypovolemic shock triggers hypoxia and systemic inflammatory response syndrome (SIRS). ...
Introduction: Durring the immune-inflammation cascade in trauma patients, the roles of polymorphonuclear cells (PMNs) and inflammatory cytokines are very important; however, there is little research in this area, especially for patients with multiple traumas. This study aimed to determine the effects of inflammatory cytokines and apoptosis of PMNs on the prognosis of patients with multiple traumas in tertiary medical centers. Materials and methods: The study subjects were patients with multiple severe traumas who had visited the emergency department. More specifically, patients with multiple traumas included those who had visited the emergency department because of trauma and presented with trauma in more than two body regions. The severity of the traumas was evaluated using the Glasgow coma scale (GCS) and abbreviated injury scale (AIS). In addition, prognostic factors including the length of the hospital stay in the intensive care unit (ICU), the condition upon discharge from the emergency department (discharge, hospitalization in a general ward, hospitalization in the intensive care unit, transfer to a different hospital, surgical operation, death, etc.), outcome of the surgical operation, and presence of infection were examined. To examine the inflammatory response factors, blood samples were obtained. Flow cytometry was performed to analyze PMN cell apoptosis. For comparative analysis, the patients were categorized according to their admission type and the presence of hemorrhagic shock. Results: Ninety-six patients were enrolled in the study (mean age 51.4 ± 16.7 years). When inpatients that had been admitted to the ICU were compared with general-ward inpatients, apoptosis, ROS, MIF, TNF-α, and IL-6 levels were found to be higher, with levels of TNF-α showing a statistically significant difference (726.7 ± 1524.2 vs. 37.5 ± 83.0, P = 0.037). PMN cell apoptosis was rarely observed in shock patients compared with non-shock patients (5.1 ± 5.8 vs. 15.0 ± 26.1, P = 0.004). When subjects were classified based on AIS (11 points or more, no more than 11 points), no significant differences were found between groups. Conclusion: Findings of laboratory tests targeting trauma patients who required hospitalization showed that levels of inflammatory cytokines such as TNF-α were increased in ICU-hospitalized patients. PMN cell apoptosis was reduced according to the initial laboratory data of patients with hemorrhagic shock in the emergency department.
... However, no study has investigated which subjects would bene t most from this approach, when considering factors such as age, injury mechanism, setting, or the presence or absence of hypotension [26]. The in uence of these approaches on coagulation has not been su ciently examined, even in animal studies and the overall effectiveness of permissive hypotension/ hypotensive resuscitation is still inconclusive and mandates further research [10][11][12]21]. ...
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Objectives To compare the pre-hospital treatment and intervention regimen for major trauma patients with comparable injury patterns between Austria (AUT) and Germany (GER). Patients and Methods This analysis is based on data retrieved from the TraumaRegister DGU®. Data included severely injured trauma patients with an Injury Severity Score (ISS) ≥ 16, an age ≥ 16, and who were primary admitted to an Austrian (n=4.186) or German (n=41.670) Level I Trauma Center from 2008 to 2017. Endpoints included pre-hospital times and interventions performed until final hospital admission. The analyzed data include patients’ demographics, mode of transportation, pre-hospital time management, hemodynamic stability, and various pre-hospital interventions. Results The cumulative time for transportation from the site of accident to the hospital did not significantly differ between the countries (62 min. in AUT, 65 min. in GER). Overall, 53% of all trauma patients in AUT were transported to the hospital with a helicopter compared to 37% in GER (P<0.001). The rate of intubation - 48% in both countries, the number of chest tubes placed (5.7% GER, 4.9% AUT), and the frequency of administered catecholamines (13.4% GER, 12.3% AUT) was comparable (Φ=0.00). Hemodynamic instability upon arrival in the TC was higher in AUT, (20.6% vs. 14.7% in GER; P<0.001). A median of 500mL of fluid was administered in AUT, whereas in GER 1000mL were infused (P<0.001). Patient demographics did not reveal a relationship (Φ=0.00) and the majority of patients sustained a blunt trauma (96%). Conclusion A significant higher number of Helicopter EMS transports (HEMS) were carried out in AUT. This can be explained by the overall lack of a unified transport algorithm. The authors suggest implementing an international guideline to explicitly use the HEMS system for trauma patients only a) for the rescue/care of people who have had an accident or are in life-threatening situations, b) for the transport of emergency patients with ISS>16, c) for transport of rescue personnel to hard-to-reach regions or, d) for the transport of medicinal products. Further, the amount of administered fluid in the pre-clinical setting should follow the concept of permissive hypotension/ hypotensive resuscitation, however the data are still inconclusive and mandate further research.
Trauma patients present a unique challenge to anesthesiologists, since they require resource-intensive care, often complicated by pre-existing medical conditions. This fully revised new edition focuses on a broad spectrum of traumatic injuries and the procedures anesthesiologists perform to care for trauma patients perioperatively, surgically, and post-operatively. Special emphasis is given to assessment and treatment of co-existing disease, including surgical management of trauma patients with head, spine, orthopedic, cardiac, and burn injuries. Topics such as training for trauma (including use of simulation) and hypothermia in trauma are also covered. Six brand new chapters address pre-hospital and ED trauma management, imaging in trauma, surgical issues in head trauma and in abdominal trauma, anesthesia for oral and maxillofacial trauma, and prevention of injuries. The text is enhanced with numerous tables and 300 illustrations showcasing techniques of airway management, shock resuscitation, echocardiography and use of ultrasound for the performance of regional anesthesia in trauma.
The Republic of Singapore Air Force (RSAF) provides Helicopter Search-and-Rescue (SAR) and Helicopter Medical Evacuation (Heli-Medevac) coverage for the Singapore Aeronautical Search and Rescue Region (ASSR) in the South China Sea, spanning 840,000 km². This region contains busy international shipping lanes and air traffic routes. Each year, Singapore's Helicopter SAR and Heli-Medevac service would be activated multiple times to rescue personnel lost at sea or to evacuate ill and injured ship sailors or passengers to tertiary hospitals in Singapore for stabilization and advanced care. This is a retrospective review on all civilian SAR and Heli-medevac activations by the RSAF over a 5-year period from 2016 to 2020. Case profiles, presenting conditions, in-flight treatment, and patient outcomes were reviewed and discussed. Key operational observations made from RSAF's SAR and Heli-Medevac, as well as lessons learned from these missions, are discussed in this article.
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Cardiac Arrest is a non-communicable disease related with unusually high levels of blood pressure. Yet Medical specialists are facing the intolerable augmenting causes of cardiac arrest towards human body as a very key global issue for a number of years. The study aims to assess the applications of the radio frequency that affects on individual's heart within body boundary. Key health information tools poised from experimental specimens on cats and dogs and their living status challenges in risks with fundamental principles are highlighted. The study shows that the prevalence of cardiac arrest was in peak in the world gradually within the period of 2010 to 2020. The study represents the blood circulation speed fluctuates with infection due to misuse of prevaricated radio frequency within GPS locations due to active open-eyes, self-voice, over excess weight and nearby cellular phone. The findings reflect the significance in cardiac arrest through effective prevention and medication that the physicians provide. The study also found the municipal hospitals are in risks due to expansion of insecure innovative technology. Scientific healthcare knowledge is indispensable for recovery from sensor effect on sudden cardiac arrest but such knowledge is poorly identified. Health providers and patients extremely use wireless sensor networks, but clinical supports are still below par. Overall, the study contributes to the heart foundation society through development of dynamic healthcare innovative technological framework indicating effective solutions on cardiac arrest. The study suggests future research trajectories of a new sophisticated alternative treatment approach to promote mental health and well-being linking with Sustainable Development Goals 2030.
Trauma is a leading cause of death. Optimal outcomes depend on a coordinated effort. Providers must be prepared to act in an organized and methodical manner. Recognizing and immediately treating causes of shock after trauma offer the best chance of survival to the patient. Incorporating evidence-based knowledge and resuscitation techniques learned from the military, the trauma victim experiencing acute hypovolemia has better outcomes because of advances in the clinical management of blood loss than ever before. Treatment focuses primarily on stopping the bleeding, providing damage control resuscitation, and monitoring and treating the patient for signs of shock. If the patient can be stabilized and avoid the lethal trauma triad, definitive surgical care can be achieved.
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Background There is still an ongoing battle against the Permissive Hypotension (PH) through Conventional Resuscitation Strategies (CR). Active fluid resuscitation in patients with traumatic shock can bring many problems, as it is known that standard high-volume resuscitation can exacerbate the lethal triad of acidemia, hypothermia, and coagulopathy. As a part of damage control resuscitation strategy, it can reduce mortality and shorten hospital stay, compared with the use of standard liquids. Moreover, its application is gradually receiving wider attention (1) . This review evaluated the effectiveness and safety of permissive hypotension resuscitation in adult patients with traumatic hemorrhagic shock.Methods The systematic review and meta-analysis were conducted according to PRISMA guidelines. We searched PubMed, EMBASE and Cochrane databases for randomized controlled trials (RCTs) from the beginning to March 2021 to compare the therapeutic effects of controlled fluid resuscitation and conventional fluid resuscitation on patients with traumatic hemorrhagic shock. Two reviewers independently conducted screening, data extraction and bias assessment. Data analysis was performed using Cochrane Collaboration Software Revman 5.2. The primary outcome was 30-day or in-hospital mortality. Secondary outcomes included blood routine index, coagulation function, resuscitation fluid use, complications, and length of hospital stay. Pooling was performed with a random-effects model.Results8 randomized controlled trials were screened out of 898 studies and 1593 patients were evaluated. The target blood pressure of the intervention group ranged from 50-90 mmHg in systolic pressure or mean arterial pressure ≥ 50 mmHg, while that of the control group was 65-110 mmHg systolic pressure or mean arterial pressure ≥ 60 mmHg. Only patients with penetrating injuries were evaluated in two studies, while the remaining six included blunt injuries. A statistically significant reduction in mortality was observed in the intervention group (RR = 0.70; 95%CI= 0.58-0.84; P < 0.05). Small heterogeneity was observed in the included articles (χ2 = 8.9; P = 0.18; I ² = 33%). The loss of platelet (PLT), hemoglobin (Hb) and body fluid was properly protected, the amount of resuscitation fluid was reduced, and the incidence of some adverse events was effectively reduced. There was no significant difference in coagulation time and hospital stay between the two groups.Conclusions This meta-analysis reveals the survival benefits of hypotension resuscitation in patients with traumatic hemorrhagic shock. The significant advantage is to promote the recovery of patients' physical function and reduce the incidence of treatment-related complications such as acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and multiple organ dysfunction syndrome (MODS), which reduces the mortality. Convincing evidences are provided based on these results, but larger, multicenter, randomized trials are needed to confirm the findings.
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Background: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. Methods: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.govNCT00375258, and South African Clinical Trial RegisterDOH-27-0607-1919. Findings: 10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14.5%] tranexamic acid group vs 1613 [16.0%] placebo group; relative risk 0.91, 95% CI 0.85-0.97; p=0.0035). The risk of death due to bleeding was significantly reduced (489 [4.9%] vs 574 [5.7%]; relative risk 0.85, 95% CI 0.76-0.96; p=0.0077). Interpretation: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients. Funding: UK NIHR Health Technology Assessment programme, Pfizer, BUPA Foundation, and J P Moulton Charitable Foundation.
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BACKGROUND: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. METHODS: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of, significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator. Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other. All analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.govNCT00375258, and South African Clinical Trial RegisterDOH-27-0607-1919. FINDINGS: 10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14.5%] tranexamic acid group vs 1613 [16.0%] placebo group; relative risk 0.91, 95% CI 0.85-0.97; p=0.0035). The risk of death due to bleeding was significantly reduced (489 [4.9%] vs 574 [5.7%]; relative risk 0.85, 95% CI 0.76-0.96; p=0.0077). INTERPRETATION: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients. FUNDING: UK NIHR Health Technology Assessment programme, Pfizer, BUPA Foundation, and J P Moulton Charitable Foundation.
To identify an appropriate diagnostic tool for the early diagnosis of acute traumatic coagulopathy and validate this modality through prediction of transfusion requirements in trauma hemorrhage. Prospective observational cohort study. Level 1 trauma center. Adult trauma patients who met the local criteria for full trauma team activation. Exclusion criteria included emergency department arrival >2 hrs after injury, >2000 mL of intravenous fluid before emergency department arrival, or transfer from another hospital. None. Blood was collected on arrival in the emergency department and analyzed with laboratory prothrombin time, point-of-care prothrombin time, and rotational thromboelastometry. Prothrombin time ratio was calculated and acute traumatic coagulopathy defined as laboratory prothrombin time ratio >1.2. Transfusion requirements were recorded for the first 12 hrs following admission. Three hundred patients were included in the study. Laboratory prothrombin time results were available at a median of 78 (62-103) mins. Point-of-care prothrombin time ratio had reduced agreement with laboratory prothrombin time ratio in patients with acute traumatic coagulopathy, with 29% false-negative results. In acute traumatic coagulopathy, the rotational thromboelastometry clot amplitude at 5 mins was diminished by 42%, and this persisted throughout clot maturation. Rotational thromboelastometry clotting time was not significantly prolonged. Clot amplitude at a 5-min threshold of ≤35 mm had a detection rate of 77% for acute traumatic coagulopathy with a false-positive rate of 13%. Patients with clot amplitude at 5 mins ≤35 mm were more likely to receive red cell (46% vs. 17%, p < .001) and plasma (37% vs. 11%, p < .001) transfusions. The clot amplitude at 5 mins could identify patients who would require massive transfusion (detection rate of 71%, vs. 43% for prothrombin time ratio >1.2, p < .001). In trauma hemorrhage, prothrombin time ratio is not rapidly available from the laboratory and point-of-care devices can be inaccurate. Acute traumatic coagulopathy is functionally characterized by a reduction in clot strength. With a threshold of clot amplitude at 5 mins of ≤35 mm, rotational thromboelastometry can identify acute traumatic coagulopathy at 5 mins and predict the need for massive transfusion.
Timely initiation of a massive transfusion (MT) protocol is associated with improved survival and reduced transfusion for patients requiring MT; however, a priori identification of this population is difficult. The objective of this study was to compare the results of an MT prediction model and actual MT incidence in combat casualties. We performed a retrospective review of the Joint Theater Trauma Registry transfusion database for all US service personnel injured in combat during overseas contingency operations who received at least 1 unit of blood. Systolic blood pressure at the time of admission, heart rate, hemoglobin, international normalized ratio, and base deficit were used in a previously developed prediction model for MT. Casualties (n = 1124) were identified who had received at least 1 unit of blood and had all data points. Of these patients, 420 patients (37%) received an MT. Subjects presenting with any two of four possible variables (heart rate >110, systolic blood pressure <110 mm Hg, base deficit < or = -6, and hemoglobin <11) had a 54% incidence of MT with a model sensitivity of 69%. Patients predicted but not observed to receive an MT had earlier time of death and an increased incidence of head injuries compared with those predicted and observed to receive an MT. Patients not predicted but observed to receive an MT had increased chest, abdominal, and extremity injuries than those neither predicted nor observed to receive an MT. The decision to implement an MT seems to rely heavily on clinical evaluation of severity of abdominal and extremity injury rather than physiologic derangement. Using a model based on the physiologic parameters--a more objective measure--may decrease mortality in combat casualties.
Background: Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. Objectives: To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. Search methods: We searched the Cochrane Injuries Group Specialised Register (searched 16 March 2012), Cochrane Central Register of Controlled Trials 2011, issue 3 (The Cochrane Library), MEDLINE (Ovid) 1946 to March 2012, Embase (Ovid) 1980 to March 2012, ISI Web of Science: Science Citation Index Expanded (1970 to March 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to March 2012), PubMed (searched 16 March 2012), www.clinical and We also searched the bibliographies of relevant studies and review articles. Selection criteria: Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials in pregnant women and neonates. Data collection and analysis: Two authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment. Main results: We identified 74 eligible trials; 66 of these presented mortality data.Colloids compared to crystalloids Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 21 trials compared hydroxyethyl starch with crystalloids, n = 1385 patients. The pooled RR was 1.10 (95% CI 0.91 to 1.32). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65).Colloids in hypertonic crystalloid compared to isotonic crystalloid Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR was 0.91 (95% CI 0.71 to 1.06). Authors' conclusions: There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.
The Advanced Trauma Life Support (ATLS) system classifies the severity of shock. The aim of this study is to test the validity of this classification. Admission physiology, injury and outcome variables from adult injured patients presenting to hospitals in England and Wales between 1989 and 2007 and stored on the Trauma Audit and Research Network (TARN) database, were studied. For each patient, the blood loss was estimated and patients were divided into four groups based on the estimated blood loss corresponding to the ATLS classes of shock. The median and interquartile ranges (IQR) of the heart rate (HR) systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Score (GCS) were calculated for each group. The median HR rose from 82 beats per minute (BPM) in estimated class 1 shock to 95 BPM in estimated class 4 shock. The median SBP fell from 135 mm Hg to 120 mm Hg. There was no significant change in RR or GCS. With increasing estimated blood loss there is a trend to increasing heart rate and a reduction in SBP but not to the degree suggested by the ATLS classification of shock.
Early and aggressive treatment of trauma-associated coagulopathy through transfusion of high plasma to packed red blood cell ratios is gaining favor. Whether this strategy is associated with improved survival is unclear. We performed a systematic review to determine whether higher plasma to packed red blood cell ratios compared with lower plasma to packed red blood cell ratios were associated with a survival advantage. We searched electronic databases MEDLINE, Embase, and Web of Science from 1950 to February 2010 for studies comparing mortality in massively transfused trauma cohorts receiving different plasma to packed red blood cell ratios. Two reviewers independently performed study selection. Discrepancies in study selection were resolved by discussion and consensus. Two reviewers independently extracted data from each study using a standardized form. Two authors independently assessed study quality using the Newcastle-Ottawa Scale. Eleven observational studies and no randomized controlled trials were identified. Three studies found a survival benefit with a 1:1 plasma to packed red blood cell transfusion ratio compared with either higher or lower ratios. Six studies did not examine a 1:1 ratio but concluded that higher plasma to packed red blood cell ratios improved survival. Secondary outcomes, including multiorgan system failure, packed red blood cell transfusion, respiratory outcomes, and coagulation variables, did not uniformly favor 1:1 or higher plasma to packed red blood cell ratios. Methodological flaws, including survival bias, and heterogeneity between studies preclude statistical comparisons concerning the effects of a 1:1 plasma to packed red blood cell transfusion ratio. There is insufficient evidence to support a survival advantage with a 1:1 plasma to packed red blood cell transfusion strategy. Randomized controlled trials evaluating safety and efficacy are warranted before a high plasma to packed red blood cell transfusion ratio can be recommended.