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

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

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Points & Pearls Excerpt

  • In prehospital trauma care, there is no imperative for endotracheal intubation over bag-valve mask ventilation.
  • Prehospital crystalloid fluid administration should be enough only to maintain mentation and pulses; resuscitation should instead proceed with blood or plasma, which have shown mortality benefits in selected prehospital settings.
  • Stratification by the degree of shock index may predict outcomes better than the traditional ATLS® classes of shock.
  • A delta shock index value of > 0.1 is linked to greater mortality, blood transfusion, and intensive care unit (ICU) length of stay.

Most Important References

  • American College of Surgeons. ACS TQIP massive transfusion in trauma guidelines. 2014. Accessed October 10, 2020. (Guideline)
  • Cannon JW. Hemorrhagic shock. N Engl J Med. 2018;378(4):370-379. (Review) DOI: 10.1056/NEJMra1705649
  • Sperry JL, Guyette FX, Brown JB, et al. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. N Engl J Med. 2018;379(4):315-326. (Randomized controlled trial; 501 patients) DOI: 10.1056/NEJMoa1802345
  • Shakur H, Roberts I, Bautista R, 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(9734):23-32. (Prospective; 20,211 patients) DOI: 10.1016/S0140-6736(10)60835-5
  • Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019;23(1):98. (Guideline) DOI: 10.1186/s13054-019-2347-3
  • Gonzalez E, Moore EE, Moore HB, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg. 2016;263(6):1051-1059. (Prospective; 111 patients) DOI: 10.1097/SLA.0000000000001608
  • Joseph B, Zeeshan M, Sakran JV, et al. Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta in civilian trauma. JAMA Surg. 2019;154(6):500-508. (Retrospective case control; 600 patients)
  • Cap AP, Pidcoke HF, Spinella P, et al. Damage control resuscitation. Mil Med. 2018;183(suppl_2):36-43. (Guideline) DOI: 10.1093/milmed/usy112
  • 98. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. (Prospective; 680 patients) DOI: 10.1056/NEJMoa1802345
  • Tran A, Yates J, Lau A, et al. Permissive hypotension versus conventional resuscitation strategies in adult trauma patients with hemorrhagic shock: a systematic review and meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2018;84(5):802-808. (Meta-analysis; 5 randomized trials, 1158 patients) DOI: 10.1097/TA.0000000000001816
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Publication Information

Christopher Pitotti, MD, FACEP; Jason David, MD

Peer Reviewed By

Ryan M. Knight, MD; Leslie V. Simon, DO

Publication Date

November 1, 2020

CME Expiration Date

November 1, 2023    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits

Pub Med ID: 33105073

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