An Evidence-Based Approach to Nonoperative Management of Traumatic Hemorrhagic Shock in the Emergency Department (Trauma CME)

Table of Contents

 

Hemorrhagic shock is the major preventable cause of morbidity and mortality in patients who suffer trauma. Definitive hemostasis is the primary goal, but coordination of care with prehospital providers, trauma centers, and surgical teams that is based on defined institutional protocols will ensure that these patients receive optimal care.

How does hypovolemic shock differ from other types of shock: distributive, cardiogenic, and obstructive?

What are the benefits and pitfalls of the use of tourniquets and hemostatic devices in prehospital care and in the ED?

Which clinical prediction calculators for shock are most accurate and useful? ATLS® class, shock index, delta shock index, respiratory-adjusted shock index, or ABC score?

What are the benefits and limitations of eFAST when assessing for bleeding?

Serum lactate, base deficit, fibrinogen levels, coagulation testing: what are the must-do tests? Will viscoelastic clot testing replace conventional coagulation testing?

What are the factors to consider when choosing fluids, blood products, and medications? What are the dangers?

Is REBOA appropriate for use in the ED? What is the evidence on its effectiveness?

How do different societies approach the concept of massive transfusion protocol?

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
   1. The Lethal Triad
6. Differential Diagnosis
7. Prehospital Care
   1. Stabilization
      1. Tourniquet Use
      2. Hemostatic Dressings
      3. Airway and Breathing
      4. Circulation
      5. Tranexamic Acid
      6. Temperature Management
   2. Transport
8. Emergency Department Preparation
9. Emergency Department Evaluation
   1. Assessment and Recognition of the Hemorrhagic Shock State
10. Diagnostic Studies
    1. Ultrasound and Other Imaging
    2. Laboratory Testing
    3. Viscoelastic Clot Testing
11. Treatment
    1. Hemorrhage Control With In-Hospital Hemostatic Devices
    2. Resuscitative Endovascular Balloon Occlusion of the Aorta
    3. Cardiac Arrest
    4. Resuscitative Thoracotomy
    5. Airway
    6. Breathing
    7. Circulation
       1. Fluid Resuscitation
       2. Massive Transfusion
       3. Crystalloid Therapy
       4. Whole Blood and Red Blood Cells
       5. Plasma
       6. Platelets
       7. Blood Product Ratios
       8. Permissive Hypotension
    8. Hemostatic Products
       1. Tranexamic Acid
       2. Prothrombin Complex Concentrate
       3. Direct Oral Anticoagulant Reversal Agents
       4. Fibrinogen
12. Special Circumstances and Populations
    1. Central Nervous System Injury
    2. Pediatric Patients
13. Controversies and Cutting Edge
14. Disposition
15. Key Points
16. Summary
17. Time- and Cost-Effective Strategies
18. Risk Management Pitfalls for Traumatic Hemorrhagic Shock
19. Case Conclusions
20. Clinical Pathway for Management of Traumatic Hemorrhagic Shock in the Emergency Department
21. Tables and Figures
    1. Table 1. Traumatic Hemorrhagic Shock Differential
    2. Table 2. Signs and Symptoms of Hemorrhage, by Class (ATLS®)
    3. Table 3. Clinical Prediction Calculators for Shock
    4. Figure 1. Bystander Awareness Campaign Information
    5. Figure 2. Fluid in Morison Pouch on eFAST
    6. Figure 3. TEG Waveforms in Various Coagulopathic States Showing Clot Firmness Versus Time
    7. Figure 4. ER-REBOA™ PLUS Catheter
    8. Figure 5. Zones of Aortic Occlusion in Resuscitative Endovascular Balloon Occlusion of the Aorta
22. References

Abstract

The management of traumatic hemorrhagic shock has evolved, with increasing emphasis on damage control resuscitation principles. Despite these advances, hemorrhage is still the leading preventable cause of death in trauma. This issue provides evidence-based recommendations for the assessment and treatment of traumatic hemorrhagic shock. Hemostatic techniques as well as correction of hemorrhagic hypovolemia and traumatic coagulopathy are presented. The safety and efficacy of practices such as resuscitative endovascular balloon occlusion of the aorta (REBOA), viscoelastic clot testing, and whole blood resuscitation are also reviewed.

Case Presentations

Your first patient of the night is a 45-year-old man who was involved in a highway motorcycle crash. He is complaining of abdominal and pelvic pain and had a 30-minute helicopter transport time. On arrival, his vital signs are: heart rate, 130 beats/min; blood pressure, 100/60 mm Hg; respiratory rate, 26 breaths/min; temperature, 37°C; oxygen saturation, 96% on room air; and GCS, 14. You know this patient will need fluid resuscitation, but you are unsure whether you should start with crystalloid or blood…

While stabilizing the first patient, a second patient is dropped off in the ambulance bay with an inguinal gunshot wound. This 22-year-old man has a heart rate of 140 beats/min; blood pressure, 80/40 mm Hg; respiratory rate, 28 breaths/min; temperature, 36.8°C; and oxygen saturation, 98%. He has been applying his sweatshirt to the wound, which is soaked with blood. You attempt direct pressure as the team wheels him to the trauma bay and consider your options to stop this junctional bleeding...

Then you get a request for online medical command from EMS responding to a conveyor belt accident with obvious amputation and pelvic fracture. The patient is hypotensive and tachycardic, with a 10-minute transport time. You ponder whether to activate the massive transfusion protocol now and whether he is a candidate for REBOA…

And this night is just getting started.

Introduction

Hemorrhagic shock is the major preventable cause of morbidity and mortality in patients suffering major trauma.¹ Hemorrhagic shock is defined as a form of hypovolemic shock in which severe traumatic blood loss leads to inadequate oxygen delivery to tissues. While the ultimate goal is definitive bleeding control, the resuscitative decisions up to this point are complex and frequently changing, in terms of medication and fluid choice, procedural indications, and treatment goals. This issue of Emergency Medicine Practice will review the evaluation and management decisions unique to the subset of trauma patients with hemorrhagic shock.

Critical Appraisal of the Literature

A literature search was performed in PubMed, Ovid MEDLINE^®, EMBASE, multiple evidence-based medicine reviews, and the Cochrane Database of Systematic Reviews. The search terms included: traumatic hemorrhagic shock, damage control resuscitation, massive transfusion, whole blood transfusion, and pre-hospital trauma resuscitation, with a date range from 1996 to September 2020. The following organizations‘ publications were also consulted for policies related directly to the management of traumatic hemorrhagic shock: American College of Emergency Physicians (ACEP) (0), American Academy of Emergency Medicine (AAEM) (1),² Eastern Association for the Surgery of Trauma (EAST) (1),³ American College of Surgeons Committee on Trauma (ACS COT) (2),^4,5 Advanced Trauma Life Support^® (ATLS^®) guidelines,⁶ Western Trauma Association (WTA) (2),^7,8 and Committee on Tactical Combat Casualty Care (CoTCCC) (TCCC guidelines).⁹ From this search, 124 articles, guidelines, and policies were selected for further review. Most of the literature consists of review articles, editorials, and consensus guidelines. Randomized trials are few, and often utilize disparate and restrictive exclusion criteria and endpoints for resuscitation, limiting the applicability of meta-analyses and reducing the strength of recommendations in guidelines.

Risk Management Pitfalls for Traumatic Hemorrhagic Shock

2. “I thought I’d give him 2 liters of normal saline for his tachycardia.”

Overresuscitation with crystalloids causes dilutional coagulopathy and acidosis. The 10th edition of ATLS® has reduced this initial bolus recommendation.

4. “Let’s get that abdominal CT just to confirm the bullet tract.”

Not moving surgical patients in hemorrhagic shock to the OR in a timely manner is exceptionally dangerous.

6. “The wound was too high for a tourniquet, so we just gave blood.”

Achieving hemostasis is your number 1 priority. Use manual pressure, junctional tourniquets, or hemostatic dressings to temporize until surgical intervention.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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