Makindo Medical Notes.com

Related Subjects: |Acute Haemorrhage |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma

Main Principles

• Traumatically injured patients should be transported quickly and treated by a specialised trauma centre whenever possible.
• Measures to monitor and support coagulation should be initiated as early as possible and used to guide a goal-directed treatment strategy.
• A damage-control approach to surgical intervention should guide patient management

Haemorrhage Control

• Most life-threatening bleeding from extremities observed in the civilian setting can be controlled by local compression, by either manual compression or pressure bandages applied to the wounds. Use simple dressings with direct pressure to control external haemorrhage.
• Extra local compression to the source of bleeding can also be achieved in certain penetrating injuries by Foley catheter insertion directly into the wound. Foley catheter balloon tamponade was initially described in bleeding penetrating injuries of the neck
• Major limb trauma use a tourniquet if direct pressure has failed and life-threatening haemorrhage.
• If active bleeding is suspected from a pelvic fracture after blunt high-energy trauma apply a purpose-made pelvic binder or consider an improvised pelvic binder, but only if a purpose-made binder does not fit.
• Use intravenous tranexamic acid as soon as possible in patients with major trauma and active or suspected active bleeding. Do not use intravenous tranexamic acid more than 3 hours after injury in patients with major trauma unless there is evidence of hyperfibrinolysis.

Tourniquets

• Used for uncontrolled arterial bleeding occurs as a result of mangled extremity injuries, including penetrating or blast injuries or traumatic amputations
• A tourniquet is a simple and efficient method with which to acutely control haemorrhage and has become the standard of care for the control of severe external haemorrhage following military combat injuries, and several publications report the effectiveness of tourniquets in this specific setting in adults and children.
• Tourniquet-induced pain was not often reported by patients. No evidence or opinion supports the use of tourniquets in the context of closed injuries.
• Tourniquets should be left in place until surgical control of bleeding is achieved but this time span should be restricted as much as possible.
• Improper or prolonged placement of a tourniquet can lead to complications such as nerve paralysis and limb ischaemia but these effects are rare. Some suggest a maximum application time of 2 h
• Reports from military settings describe cases in which tourniquets have remained in place for up to 6 h with survival of the extremity.
• Bleeding from most civilian wounds can be controlled using local pressure; however, uncontrolled external bleeding from either blunt or penetrating limb injury should be controlled with a tourniquet.

Pelvic Ring binders

• Patients with severe high-energy and complex pelvic trauma, haemodynamic instability and massive blood loss belong to a highly lethal group of trauma patients, and their management is time-sensitive and challenging.
• Global mortality in polytraumatised patients presenting with pelvic ring fractures remains high despite improvements in management and treatment algorithms.
• The pelvis can create a multifocal haemorrhage, including significant retroperitoneal haematoma, which may not be easily compressible or possible to manage using traditional surgical methods.
• Treatment of pelvic ring fractures requires re-approximation of bony structures to address mechanical instability, damage-control resuscitation (DCR) to restore haemostasis, assessment for associated injuries and triage of investigations. In addition, multimodal haemorrhage control [external fixation and compression (damage-control orthopaedics), retroperitoneal packing (damage-control surgery), urgent radiologic angioembolisation or resuscitative endovascular balloon occlusion of the aorta (REBOA)] by multidisciplinary trauma specialists (general surgeons, orthopaedic surgeons, endovascular surgeons/interventional radiologists) is required.
• Correctly placed pelvic binders lead to anatomical closure of the pelvic ring, with a favourable haemodynamic effect. These devices are increasingly being used in the pre-hospital setting if a pelvic fracture is suspected.
• Unstable pelvic ring fractures may be clinically and radiologically overlooked during initial assessment, especially in unconscious patients, and the time point for opening and/or removal remains controversial. In-hospital external fixation stabilises anterior pelvic ring lesions and can be combined with posterior stabilisation using percutaneous sacro-iliac screws in the presence of associated lesions to the posterior ring. The external fixator is especially useful in the acute phase, acquiring an acceptable reduction and an adequate stability in the partially unstable lesions and also reduces pelvic volume and bleeding.
• If haemodynamic instability persists, a laparotomy for haemostasis according to damage-control principles to all potentially involved systems (digestive, vascular, urinary and bone) should be performed.

Anticoagulant reversal

• Rapidly reverse anticoagulation in patients who have major trauma with haemorrhage.
• Use prothrombin complex concentrate immediately in adults (16 or over) with major trauma who have active bleeding and need an emergency reversal of a vitamin K antagonist. Do not use plasma to reverse a vitamin K antagonist in patients with major trauma.
• Do not reverse anticoagulation in patients who do not have active or suspected bleeding. Take haematology advice.
• Use physiological criteria and response to immediate volume resuscitation to activate the major haemorrhage protocol. Do not rely on a haemorrhagic risk tool applied at a single time point to determine the need for major haemorrhage protocol activation.
• For IV access with major trauma in pre-hospital settings use peripheral intravenous access or if peripheral intravenous access fails, consider intra-osseous access

Volume Resuscitation

• Patients with active bleeding use a restrictive approach to volume resuscitation until definitive early control of bleeding has been achieved.
• In pre-hospital settings, titrate volume resuscitation to maintain a palpable central pulse (carotid or femoral).
• In hospital settings, move rapidly to haemorrhage control, titrating volume resuscitation to maintain central circulation until control is achieved.
• For patients who have haemorrhagic shock and a traumatic brain injury: if haemorrhagic shock is the dominant condition, continue restrictive volume resuscitation or if traumatic brain injury is the dominant condition, use a less restrictive volume resuscitation approach to maintain cerebral perfusion.
• In pre-hospital settings only use crystalloids to replace fluid volume in patients with active bleeding if blood components are not available.
• In hospital settings do not use crystalloids for patients with active bleeding
• For adults (16 or over) use a ratio of 1 unit of plasma to 1 unit of red blood cells to replace fluid volume.
• For children (under 16s) use a ratio of 1 part plasma to 1 part red blood cells, and base the volume on the child's weight.

Damage control surgery

• Use damage control surgery in patients with haemodynamic instability who are not responding to volume resuscitation.
• Consider definitive surgery in patients with haemodynamic instability who are responding to volume resuscitation.
• Use definitive surgery in patients whose haemodynamic status is normal.

References

• European Guidelines on Bleeding in trauma
• NICE guidelines on Trauma