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.
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.
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.
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.
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.
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.
The Lethal Triad
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Dr. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Join him as he takes you through the November 2020 issue of Emergency Medicine Practice: An Evidence-Based Approach to Nonoperative Management of Traumatic Hemorrhagic Shock in the Emergency Department (Trauma CME)
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Why to Use
When used individually, blood pressure and heart rate may fail to predict accurately the severity of hypovolemia and shock in major trauma. When initiated inappropriately, massive transfusion of blood products can be associated with significant risk. Identifying patients who are likely to require massive transfusion can be difficult, and objective measures such as the shock index can help. The shock index has also been shown to be more sensitive than the ABC score for massive transfusion (Schroll 2018).
When to Use
The accuracy of the shock index for identifying trauma patients in need of massive blood transfusion has not yet been prospectively investigated.
Kamal Medlej, MD
The shock index was first proposed in the literature in 1967 by Allgöwer and Burri as a measure of shock severity. More recently, the shock index has been studied further with modern protocols.
In a retrospective study by Mutschler et al (2013), 21,853 patients were identified in a trauma registry. Each patient’s shock index value was calculated based on vital signs taken on arrival at the emergency department. The degree of shock was found to correlate with increasing shock index values. The need for blood products, fluids, and vasopressors was also found to increase with higher shock index values.
A retrospective study by Cannon et al (2009), performed at a single Level I trauma center, identified 2445 patients admitted over a 5-year period. Patients with a shock index value > 0.9 were found to have a significantly higher mortality rate (15.9%) when compared with patients with a normal shock index (6.3%)
In a retrospective registry study by Vandromme et al (2011), the authors identified 8111 patients with blunt trauma who were admitted at a single Level I trauma center over an 8-year period. The shock index value for each patient was calculated from recorded prehospital vital signs, and patients with a shock index value > 0.9 were found to have a 1.6-fold higher risk for massive transfusion.
In a retrospective study of 542 patients who underwent emergency intubation, Heffner et al (2013) identified a pre-intubation shock index value ≥ 0.9 to be independently associated with peri-intubation cardiac arrest.
A retrospective study of 2524 patients at a single center who were screened for severe sepsis found that a shock index value ≥ 0.7 performed as well as the SIRS (systemic inflammatory response syndrome) criteria in negative predictive value and was the most sensitive screening tool for hyperlactatemia and 28-day mortality (Berger 2013).
The Protocolized Care for Early Septic Shock (ProCESS) trial (a large, multicenter prospective randomized controlled trial that enrolled 1341 patients) compared 3 different protocols for re-suscitation of septic patients, including a protocol that used a shock index value ≥ 0.8 as a fluid resuscitation goal. The study found no significant difference in mortality between the 3 intervention groups (Yearly 2014).
Manuel Mutschler, MD
Why to Use
Early initiation of massive transfusion has been shown to improve survival in critical trauma patients. The ABC score reduces delay in determining need for massive transfusion in a trauma patient, while also providing consistency in appropriateness of transfusion by minimizing practice variations among clinicians.
When to Use
The ABC score should be used in trauma patients for whom massive transfusion is being considered.
Cullen Clark, MD
Activation of a massive transfusion protocol (MTP) triggers the release of packed red blood cells, platelets, and fresh frozen plasma at frequent intervals until the MTP is called off.
The original study (Nunez 2009) was a retrospective review performed at Vanderbilt University Medical Center using the institution’s trauma registry. The study population was derived from all trauma patients admitted to the hospital over the course of a year (n = 596). Patients included were Level I trauma activations transported directly from the scene who received any blood transfusion while admitted. The ABC score was created by the trauma faculty based on clinical experience, and logistic regression modeling was used to determine the odds ratio of requiring MTP for each parameter of the score.
Of the total cohort, 76 patients (12%) required massive transfusion in the first 24 hours. Based on the number of patients who received massive transfusion and were identified using the ABC score, researchers found the best cutoff to be a score ≥ 2, giving a sensitivity of 75% and specificity of 86%. Compared with the Trauma Associated Severe Hemorrhage scoring system and the McLaughlin score using the same dataset, the ABC score was shown to be the most accurate in predicting need for MTP.
The validation study (Cotton 2010) was a retrospective review using trauma databases from 3 institutions: Vanderbilt University Medical Center, Johns Hopkins Hospital, and Parkland Memorial Hospital. The inclusion and exclusion criteria were the same as the original study. The study population was again derived from trauma patients admitted to 1 of the 3 hospitals over the course of a year. The sample size of the study was 1604, including 586 patients from the original study. There was significant variation in demographics between the centers involved, but the massive transfusion rate in the first 24 hours of admission was similar for each hospital (approximately 15%). There was little variability between each institution’s cohort in the percentage of patients correctly classified as meeting the ABC score cutoff for MTP, among those who received massive transfusions. For each institution, sensitivity ranged from 76% to 90% and specificity ranged from 67% to 87%. Negative predictive value was 97% and positive predictive value was 55%.
The validation study also measured the accuracy of the ABC score at predicting need for massive transfusion in the first 6 hours of admission. Sensitivity was 87% and specificity was 82%, with slightly higher negative predictive value (98%) and lower positive predictive value (55%) compared to prediction of massive transfusion need in the first 24 hours.
The major limitation to both studies was their retrospective nature. A prospective trial is ongoing. The study shows a novel means of quickly predicting the need for massive transfusion based on objective measures. While there are good data showing that early activation of MTP improves survival rates in severely injured trauma patients, a prospective study will be necessary to determine whether utilization of the ABC score improves patient outcomes.
Bryan Cotton, MD
Christopher Pitotti, MD, FACEP; Jason David, MD
Ryan M. Knight, MD; Leslie V. Simon, DO
November 1, 2020
December 1, 2023
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
Date of Original Release: November 1, 2020. Date of most recent review: October 10, 2020. Termination date: November 1, 2023.
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AAFP Accreditation: This Enduring Material activity, Emergency Medicine Practice, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 07/01/2020. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Approved for 4 AAFP Prescribed credits.
AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours per issue by the American Osteopathic Association.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME credits.
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