While not much is new in the world of hustlin’, when it comes to trauma resuscitation, the game done changed*. It was easier in the old days: 2L of crystalloid for a hypotensive patient, and then blood. While new science on trauma resuscitation has helped us understand how flawed that paradigm is, the new school can be some tricky water to navigate. From damage control to fibrinogen, from TXA to thromboelastometry, there is no doubt that resuscitating a bleeding trauma patient is a more nuanced endeavor than we originally envisioned it.
So, inspired by Biggie’s Descartesian ten-point discourse on method, I present the ten rules of the contemporary trauma resuscitation game...
Staff Emergency Medicine Physician with a niche and passion for --> trauma, austere medicine, damage control resuscitation and prolonged field care
There is change afoot however. ACLS is emphasizing a C-A-B approach with more emphasis on early and continuous chest compressions and less on advanced airway management, especially in the field.
Similarly, for trauma, we must change our approach. We have the benefit of learning from our military colleagues and advancing our own civilian practice to what makes physiologic sense – if you attempt to perform an RSI on an under-resuscitated patient who is still actively bleeding, the chance of them suffering post-intubation hypotension and arrest is extremely high.
Here we talk about the initial management of the patient within the “golden hour” (the hour in which if we resuscitate the patient we may prevent death). So what do we do in that first hour?
Addressing traumatic injuries is a major component of Emergency Medicine (EM) practice. Providers are asked to quickly evaluate these patients, address major life threats, and make a full inventory of injuries. Having a systematic approach is essential to a rapid assessment that minimizes the chance of missing injuries. This post will outline a step-by-step approach to evaluation.
For identifying bleeding into abdominal, pleural, or pericardial cavities, we can use the bedside ultrasound (e-FAST exam). In the hemodynamically unstable patient with normal e-FAST, one should think pelvic injuries.
ACEP supports efforts to ensure that there are evidence-based national standards of trauma practice and the promulgation of those standards in the creation of safe trauma systems. Emergency physicians, given their central role in the care of these patients, must play an important role in the development and validation of these standards.
This review summarizes the evolution of trauma resuscitation, offering clinicians the
knowledge base to enable the highest standards of clinical care. Trauma resuscitation
has evolved from a one-size-fits-all approach to one tailored to patient physiology.
For the past decade, my mentor, Professor Geoffrey Dobson, and I have been developing ALM, a novel fluid therapy for use on the battlefield. We’ve shown that ALM can slow biological time and potentially buy the 10 minutes required to save a life.
ALM is a combination of three drugs: adenosine, lidocaine and magnesium. It rescues and stabilises the heart, protects the organs and stops bleeding. ALM’s capacity to increase survival rates in hostile environments is a potential game changer for the US military, which has funded our research since 2012.
Regarding the classification of hemorrhage shock, always start with the patient’s vitals. The finding of a narrow pulse pressure should alert you to the potential for bleeding. For example, if a patient arrives following a GSW to the abdomen and the initial BP reads 140/115, this should not be interpreted as normal!!!! In hemorrhagic shock, the loss of intravascular volume results in decreased preload, stroke volume, and cardiac output.
How can we most readily identify occult shock, the silent killer in trauma? What are 7 actions to consider in the first 15 minutes of resuscitation? How can the concepts of “controlled resuscitation” and “resuscitation intensity” help us decide resuscitation targets and when to activate a massive transfusion protocol? and many more…
While not much is new in the world of hustlin’, when it comes to trauma resuscitation, the game done changed*. It was easier in the old days: 2L of crystalloid for a hypotensive patient, and then blood. While new science on trauma resuscitation has helped us understand how flawed that paradigm is, the new school can be some tricky water to navigate.