https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(00)02689-1.pdf

Traumatic brain injury.

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

/pdf/the-european-guideline-on-management-of-major-bleeding-and-50g3zxrre8.pdf

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

The world-wide impact of traumatic injury and associated hemorrhage on human health and well-being cannot be overstated. Twelve percent of the global disease burden is the result of violence or accidental injury. Hemorrhage is responsible for 30 to 40% of trauma mortality, and of these deaths, 33 to 56% occur during the prehospital period. Among those who reach care, early mortality is caused by continued hemorrhage, coagulopathy, and incomplete resuscitation. The techniques of early care, including blood transfusion, may underlie late mortality and long-term morbidity. While the volume of blood lost cannot be measured, physiologic and chemical measures and the number of units of blood given are readily recorded and analyzed. Improvements in early hemorrhage control and resuscitation and the prevention and aggressive treatment of coagulopathy appear to have the greatest potential to improve outcomes in severely injured trauma patients.

Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations.

: Rapid progress in trauma care occurs when the results of translational research are promptly integrated into clinical practice. Experience with a high volume of severely injured casualties expedites the process. Historically, these conditions have converged during times of conflict, improving the care of combat casualties and subsequently that of civilian trauma patients. In the most severely injured casualties, we know that when the lethal triad of hypothermia, acidosis, and coagulopathy are present, death is imminent. Current teaching is to avoid reaching these conditions by using damage control surgery. However, conventional resuscitation practice for damage control focuses on rapid reversal of acidosis and prevention of hypothermia, and surgical techniques focus on controlling hemorrhage and contamination. Direct treatment of coagulopathy has been relatively neglected, viewed as a byproduct of resuscitation, hemodilution, and hypothermia, and delayed by blood banking logistics. Damage control resuscitation addresses the entire lethal triad immediately upon admission to a combat hospital. By demonstrating that in the severely injured the coagulopathy of trauma is present at admission, recent studies have brought back to light the importance of treating this disorder at an earlier stage. Reports of lactated Ringer s solution and normal saline increasing reperfusion injury and leukocyte adhesion lead one to conclude that the standard crystalloid based resuscitation guidelines in pre hospital trauma life support (PHTLS) and advanced trauma life support (ATLS) may worsen the presenting acidosis and coagulopathy in severely injured trauma patients, and possibly increase ARDS, SIRS, and MOF. The safety of withholding PRBCs in hemodynamically stable patients has been demonstrated,18 and the risks associated with blood transfusion are well described.

Damage control resuscitation: Directly addressing the early coagulopathy of trauma

Objective
Circulatory shock is a life-threatening syndrome resulting in multiorgan failure and a high mortality rate. The aim of this consensus is to provide support to the bedside clinician regarding the diagnosis, management and monitoring of shock.

/pdf/consensus-on-circulatory-shock-and-hemodynamic-monitoring-4ifwfxi7xc.pdf

Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine

Background Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso. Methods We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a prehospital systolic blood pressure ≤ 90 mm Hg. The study setting was a city with a single centralized system of prehospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room. Results Among the 289 patients who received...

http://www.nimbot.com/Med/Articles/Journal%20Clubs/2007-01/Immediate%20vs%20Delayed%20Fluid%20Resuscitation%20for%20Hypotensive%20Pts%20with%20Penet%20Torso%20Injuries/Article.pdf

Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.

Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries

The critical decisions in patients with thoracoabdominal trauma are establishing the need to explore either or both cavities and determining appropriate sequencing. The causes and patterns of management difficulties were analyzed in 82 consecutive patients with penetrating thoracoabdominal injuries. Nine thoracotomies (11%) and 16 laparotomies (22%) were negative, with the major causes being misleading chest tube outputs, bullet trajectories, and abdominal tenderness. Inappropriate sequencing occurred in 19 patients (23%), and 15% required reoperation within 24 hours. Pitfalls and misjudgements in management of penetrating thoracoabdominal injuries occur in distinct patterns. The unreliability of chest tube output and abdominal examination must be kept in mind, and intraoperative clues of ongoing hemorrhage outside the operative field must be sought.

Double jeopardy: thoracoabdominal injuries requiring surgical intervention in both chest and abdomen.

Missed injuries have a bad reputation and are sometimes associated with serious morbidity for the patient and personal embarrassment for the surgeon. During a 10-year period, 123 missed injuries in 117 patients requiring re-operation were encountered in one trauma center. A retrospective review of causes and patterns was undertaken. The most common presentation was delayed hemorrhage (64 injuries). The colon, thoracic vasculature, chest wall arteries, and diaphragm were the most frequently involved sites. Forty-six injuries were overlooked during the diagnostic work-up, and 43 were missed during surgery. Technical problems with diagnosis and surgery accounted for 62% of missed injuries, whereas decision and judgment errors accounted for the rest. Further insight was provided by the classification of missed injuries into three types. Type I (20%) occurred outside the body area of clinical focus, whereas type II (69%) occurred within it. Type III (11%) resulted when instability of the patient necessitated interruption of the diagnostic work-up or exploration. Each type represents a different clinical pattern and dictates a specific preventive strategy.

Mary K. Allen

Papers

Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.

Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries

Double jeopardy: thoracoabdominal injuries requiring surgical intervention in both chest and abdomen.

Causes and patterns of missed injuries in trauma

Systematic approach to pneumothorax, haemothorax, pneumomediastinum and subcutaneous emphysema.