Med Intensiva.

2014;38(8):502---512

www.elsevier.es/medintensiva

UPDATE IN INTENSIVE CARE: TRAUMA AND CRITICAL CARE UPDATE

Resuscitative goals and new strategies in severe

trauma patient resuscitation夽
J.J. Egea-Guerrero a,b,∗ , M.D. Freire-Aragón a , A. Serrano-Lázaro c , M. Quintana-Díaz d ,
Grupo de Trabajo de Trauma y Neurointensivismo de SEMICYUC

a
Unidad de Neurocríticos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
b
Instituto de Biomedicina (IBiS)/CSIC Universidad de Sevilla, Sevilla, Spain
c
Unidad de Cuidados Intensivos, Hospital Clínico Universitario de Valencia, Valencia, Spain
d
Unidad de Cuidados Intensivos, Hospital Universitario de La Paz, Madrid, Spain

Received 16 April 2014; accepted 16 June 2014

KEYWORDS Abstract Traumatic injuries represent a major health problem all over the world. In recent
Traumatic injuries; years we have witnessed profound changes in the paradigm of severe trauma patient resuscita-
Goals; tion; new concepts regarding acute coagulopathy in trauma have been proposed; and there has
Transfusion; been an expansion of specific commercial products related to hemostasis, among other aspects.
Coagulopathy; New strategies in severe trauma management include the early identification of those injuries
Intensive Care Unit that are life threatening and require surgical hemostasis, tolerance of moderate hypotension,
rational intravascular volume replacement, prevention of hypothermia, correction of acido-
sis, optimization of oxygen carriers, and identification of those factors required by the patient
(fresh frozen plasma, platelets, tranexamic acid, fibrinogen, cryoprecipitates and prothrombin
complex). However, despite such advances, further evidence is required to improve survival
rates in severe trauma patients.
© 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

PALABRAS CLAVE Objetivos y nuevas estrategias de resucitación en el paciente traumatizado grave

Lesiones traumáticas;
Objetivos; Resumen Los traumatismos son uno de los principales problemas de salud en todo el mundo. En
Transfusión; los últimos años hemos presenciado profundas modificaciones en el paradigma de la resucitación
Coagulopatía; del paciente traumatizado crítico, se han desarrollado nuevos conceptos en relación con
Unidad de Cuidados la coagulopatía inducida por el trauma, así como hemos asistido a la expansión comercial
Intensivos de productos específicos relacionados con la hemostasia, entre otros. Las nuevas estrategias de
resucitación en el trauma incluyen: identificar de manera precoz las lesiones que amenazan la

夽 Please cite this article as: Egea-Guerrero JJ, Freire-Aragón MD, Serrano-Lázaro A, Quintana-Díaz M, Grupo de Trabajo de Trauma

y Neurointensivismo de SEMICYUC. Objetivos y nuevas estrategias de resucitación en el paciente traumatizado grave. Med Intensiva.
2014;38:502---512.
∗ Corresponding author.

E-mail addresses: juanjoegea@hotmail.com, juanj.egea.sspa@juntadeandalucia.es, jjegeaguerrero@gmail.com (J.J. Egea-Guerrero).

2173-5727/© 2014 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.
Resuscitative goals and new strategies in severe trauma patient resuscitation 503

vida del paciente, la detección de aquellas que precisan de un inmediato control quirúrgico o
intervencionismo radiológico, tolerar una hipotensión moderada, reponer de manera racional el
volumen intravascular, prevenir la hipotermia, evitar la acidosis, optimizar los transportadores
de oxígeno, así como identificar aquellos factores necesarios para el paciente (plasma fresco
congelado, plaquetas, ácido tranexámico, fibrinógeno, crioprecipitados y complejo protrom-
bínico). Sin embargo, a pesar de estos avances, se necesitan más evidencias para reducir las
tasas de mortalidad de los pacientes traumatizados graves.
© 2014 Elsevier España, S.L.U. y SEMICYUC. Todos los derechos reservados.

Introduction hyperglycemia. This ‘‘lethal pentad’’ results in a decrease in

oxygen available at tissue level, secondary to hypoperfusion,
Traumatic injuries remain a major healthcare, social and with the utilization of aerobic pathways that generate
economic problem throughout the world. In recent years increased lactic acid levels and lower pH. These pathways
there have been profound changes in the paradigm of severe are less efficient in energy terms and limit endogenous
trauma patient resuscitation; new concepts regarding acute heat production---thereby worsening the existing exposure
coagulopathy induced by trauma (CIT) have been proposed; hypothermia. This circumstance, and the replacement of
and there has been an expansion of specific commercial fluids and blood products without prior warming, gives rise
products related to hemostasis, among other aspects. To to an unsustainable situation resulting in patient death sec-
a large extent, all these changes have been promoted by ondary to refractory hemorrhagic shock.1
the experience gained from armed conflicts over the last
decade, in which strategies are evaluated and subsequently
transferred to the civil setting.1---6 Guaranteeing adequate tissue perfusion
with rational fluid administration
General considerations on the new strategies During the initial phase of trauma resuscitation, the blood
of resuscitation in trauma pressure targets should be moderate, allowing systolic blood
pressure (SBP) values of between 80 and 90 mmHg.4---6 This
Damage control resuscitation (DCR) is defined as the global situation of permissive hypotension is achieved by delaying
series of structured interventions that take place during the start of fluid therapy or by limiting the infused volume.
the management of serious trauma characterized by a high The theoretical benefits of such a strategy are the main-
risk of mortality due to hemorrhagic shock. These interven- tenance of optimum/suboptimum tissue perfusion with the
tions must begin at the injury site, and must be maintained aim of avoiding clot disruption and minimizing hypother-
both in the operating room and in the Intensive Care Unit mia, the dilution of coagulation factors and blood losses
(ICU).1,2 Thus, in damage control resuscitation, effort should through uncontrolled foci.5---8 It must be taken into account
focus on the early identification of potentially fatal injuries, that blood pressure is a surrogate marker of tissue oxygen-
with simultaneous rational intravascular volume replace- ation; consequently, such blood pressure control should be
ment tolerating mild hypotension, the vigorous prevention viewed as a dynamic concept in which the thresholds are
of hypothermia, control of acidosis (or prevention of acidosis adjusted on an individualized basis in each case, considering
progression), oxygen transporter optimization, and empha- the patient history (arterial hypertension, pregnancy, etc.),
sis on the correction of CIT.3,4 The approach to this type of the expected delay until in-hospital care can be provided,
coagulopathy includes the early transfusion of fresh frozen and the type of injuries evidenced after trauma. As an exam-
plasma (FFP) and platelets, with recognition from the phy- ple, in patients with severe traumatic brain injury (TBI) or
siopathological perspective of those factors which may be acute spinal cord damage, hypotension could have delete-
needed by the patient (fibrinogen, cryoprecipitates and pro- rious effects upon secondary injuries.9 In patients of this
thrombin complex) and modulation of the hyperfibrinolysis kind, the recommended mean blood pressure value would
state making use of tranexamic acid (TXA).2,5,6 All these be ≥80 mmHg.4
interventions are time dependent and must be carried out For decades, fluid administration has been the standard
parallel to damage control surgery (DCS) --- the aim of which of practice in circulatory resuscitation of trauma patients in
is to afford emergent management of those surgical lesions shock, attempting to preserve organ perfusion by replacing
that prove life-threatening, leaving their definitive repair the blood losses. Oliguria is often present during the early
for a latter stage. stages of resuscitation. Early-stage efforts to restore urine
Failure to control any of the abovementioned aspects output would inevitably generate volume overload and an
gives rise to a vicious circle known as the ‘‘lethal triad’’ increased third space. It is known that a liberal and aggres-
(hypoperfusion/acidosis, hypothermia and coagulopathy).2 sive fluid strategy has deleterious consequences for CIT and
Some authors postulate that these three factors, classi- is related to the appearance of abdominal compartment
cally associated to mortality in trauma, should in fact syndrome or lung injury.6,7 Different in vitro studies have
be complemented by two additional factors: hypoxia and shown that the concentrations of coagulation factors and
504 J.J. Egea-Guerrero et al.

fibrinogen are directly proportional to the volume adminis- with unresolved problems such as underdiagnosed serious
tered to the patient after trauma.10,11 The study conducted lesions.22,23 Recently, a prospective study has shown early
by Bickell et al.12 in a group of penetrating trauma patients lactate clearance (0---2 h) to be an important prognostic
revealed benefits in terms of survival when a lesser fluid factor. The follow-up of lactate levels therefore could be
volume was used during resuscitation. However, later stud- very useful in the context of trauma resuscitation.22
ies have obtained variable results.13,14 The latest review of
the Cochrane Database, assessing ideal timing of the start Avoiding coagulopathy induced by trauma
of resuscitation with fluids as well as the amount of volume
to be administered in patients with hemorrhagic shock, Patient age, personal history and genetic characteristics,
does not allow firm conclusions to be drawn.15 and the type of injury or its seriousness, among others,
The use of crystalloids in initial resuscitation is the are non-modifiable factors following trauma.24 We there-
standard of practice and the recommendation established fore must act upon those potentially reversible factors that
for both advanced trauma life support (ATLS) and the dif- contribute to worsen CIT. In this regard, bleeding in trauma
ferent clinical practice guides.4 Nevertheless, the use of patients can often be controlled provided early and appro-
high-dose isotonic saline solutions may give rise to a situ- priate measures are taken. However, hemorrhagic shock
ation of hyperchloremic acidosis.7 Immunological studies of remains the cause of death in over 40% of all serious trauma
the different types of fluids show that the l-isomer of Ringer patients. Between 33% and 56% of these deaths occur in
lactate solution could induce less inflammatory and immune the pre-hospital period, with the documentation of up to
dysfunction, as well as fewer electrolyte disorders. How- 81% within the first 6 h of admission to hospital. Following
ever, it must be emphasized that Ringer lactate in patients the first 24 h, the main cause of death in trauma patients
with brain damage would not be a choice, because of its tends to be multiorgan failure or intracranial hypertension,
hypotonic characteristics.16 in cases of serious TBI.25
The use of colloids has been unable to demonstrate ben- It must be taken into account that up to 25---43% of all
efits with respect to crystalloids in the critical patient. trauma patients that reach the hospital have coagulation
Although all fluids are able to cause dilutional coagulopathy, disorders.26---28 The origin of CIT is multifactorial, and is illus-
colloids produce anomalies in fibrinogen polymerization and trated in Fig. 1. Of the different causes, mention should
lesser clot stability---the effect being dose dependent.17 One be made of the loss of coagulation factors through the
of the latest clinical trials, the multicenter CRISTAL study bleeding sites, the dilution of coagulation factors (as a con-
involving 2857 patients, has revealed no differences in mor- sequence of fluid infusion or the administration of red cell
tality after one month between the use of crystalloids and concentrates [RC] without associated FFP), the activation of
colloids.18 Recently, the European Pharmacovigilance Risk fibrinolysis, and alterations in protease function secondary
Assessment Committee has recommended suspension of the to acidemia, hypothermia and shock.29
marketing of colloids containing hydroxyethyl-starch, due At present, dilutional coagulopathy is recognized as one
to their association to the appearance of renal failure and of the elements that favor CIT.10,11,17 However, it has been
increased mortality among critical patients.19 Accordingly, shown that such alterations can be independent of the vol-
the European guides of 2013 place special emphasis on the ume of fluids used during pre-hospital care.17,27,28 Many
need for a more adjusted use of colloids in general, referred studies have related the severity or extent of trauma to
both to time and to the volume administered, and insist on coagulation disorders.27,28 In this regard, CIT worsens in the
the importance of adhering to the doses specified in the presence of shock at hospital admission, since hypoperfusion
Summary of Product Characteristics.4 promotes hyperfibrinolysis (through the activation of throm-
Resuscitation with small doses of hypertonic saline solu- bomodulin and protein C) independently of the presence of
tion (7.5%) in hemorrhagic shock acts as an effective plasma hypothermia, acidosis or the dilution of factors, which man-
expander and plays a positive immune modulating role. ifest posteriorly in cases of inadequate resuscitation.17,29,30
Given its lesser volume and weight in comparison with other Recent studies define CIT as disseminated intravascular
fluids, hypertonic saline solution allows for easier transport coagulopathy with a fibrinolytic profile.31 Hypothermia has
and storage, especially in the military and pre-hospital sett- been described as an independent mortality risk factor in
ings. To our knowledge, however, hypertonic saline solution trauma.27,29 The correction of hypothermia improves the
has not been shown to be superior to isotonic saline in the coagulation times and platelet activity.2,32 A drop in pH to
resuscitation of critical patients.20 7.2 is associated to a 50% decrease in the generation of
Vasopressors in severe trauma, specifically noradrenalin, thrombin, a reduction in the activity of coagulation factors
are used in life-threatening situations of arterial hypoten- Va and Xa, and an increase in fibrinolysis. This decrease may
sion refractory to resuscitation with fluids. Although their reach 90% when the pH drops to 7. However, at experimental
use in the experimental setting has revealed a decrease in level, the correction of acidosis following the administra-
fluid requirements, with lesser blood losses and improved tion of bicarbonate does not improve CIT.32 This indicates
survival, studies in humans have produced contradictory that despite normalization of the pH values, if hypoper-
results, and the early administration of such drugs in trauma fusion secondary to hemorrhagic shock is not controlled, CIT
has even been associated to increased mortality.21 will persist.32,33 It should be underscored that the concen-
Since correction of the macrocirculatory hemodynamic trations of calcium---a crucial ion in blood coagulation---are
parameters does not guarantee the resolution of tissue influenced by the acid---base equilibrium and by the citrate
hypoperfusion, the initial measurements of lactate levels administered with blood products. Hence, a lack of control
or base defects, and their subsequent clearance, can allow of their levels is related to both patient mortality and the
us to identify patients with incomplete resuscitation or transfusion needs.3,34
Resuscitative goals and new strategies in severe trauma patient resuscitation 505

Red cell Personal history

Fluids Anticoagulation
concentrates Antiplatelet medication
Genetic profile
Other drugs
Hypothermia
Hypothermia

Traumatism
Loss of
factors

Factor 2+
hemodilution, Ca Ca 2+
hypocalcemia C 2+ C a 2+
2+ a
Ca
Consumption
Fibrinogen
Coagulation
Factor alterations,
factors hyperfibrinolysis
Platelets Shock,
tissue hypoperfusion

Acidosis Acidosis
Ge Ge
n n eti
eti cp
cp rof
rof ile
ile

Figure 1 Factors associated to coagulopathy induced by trauma (CIT).

The management of CIT based on conventional coagula- diseases and supply only those elements which the patient
tion studies is not advised, since the information they offer needs. However, while this concept is valid in controlled
always comes late and does not reflect the situation of the situations and elective surgery, it proves ineffective during
patient on a real-time basis.3,35,36 For this reason, the imple- the management of traumatic hemorrhagic shock.41,42
mentation of viscoelastic tests in the trauma emergency The proportions in which these components should be
ward is becoming increasingly widespread, in the same way infused have also been the subject of study and debate.
as in major surgery.36,37 It is considered that CIT could have Computational models have shown the need to increase
a series of specific characteristics with the use of these the amount of FFP and platelets administered to patients
techniques.38 Analysis using the ROTEM (ROtation ThrombE- after trauma.42 Therefore, the definition of massive bleed-
lastometry Method) shows that there is an alteration in clot ing which we use, and which was described in the 1990s as
formation time (CFT), clot amplitude after 5 min (CA5), the need for over 10 red cell concentrate units in under 24 h,
maximum clot firmness (MCF), and alpha-angle. In brief, does not precisely reflect the way in which transfusions cur-
clot formation is said to be slow, with a 40% reduction in rently should be carried out in severe trauma patients.35,41,43
its firmness.38 This information would allow the real-time The recently published results of the PROMMPT study,
and immediate adoption of specific actions for controlling which included 1245 patients in 10 trauma centers, indi-
coagulopathy at the patient bedside.37 cate a decrease in mortality when the ratios of FFP and
Coagulopathy induced by trauma is associated to platelets versus RC approach 1:1.26 These data are con-
increased transfusion needs, a greater incidence of multi- sistent with those of previous studies which found FFP:RC
organ dysfunction, a longer ICU stay and higher mortality ratios of under 1:2 to be associated with decreased mortality
rates.24,28,30 Consequently, in recent years the trauma man- after trauma.1,41,44,45 Likewise, the use of cryoprecipitates
agement strategies have focused on ways to avoid the or fibrinogen administered in relation to the number of
progression of CIT.2,3,29 infused RC also improves survival.3,46 On the basis of the
described clinical trials, a lack of homogeneity is seen in
the administration of the specified ratios, particularly dur-
Proportional transfusion of blood products ing the first few hours.26,36 In brief, it can be concluded that
the current recommendations comprise the transfusion of
The replacement of blood losses after trauma through the high FFP:RC and platelet:RC ratios (between 1:1 and 1:2),
transfusion of blood products has changed substantially with transfusion performed in a constant manner during the
in recent decades. The use of these products is known resuscitation of trauma patients.1,26,41,44,45
to increase morbidity-mortality after trauma.39 Although Of all trauma patients receiving blood products, 36%
whole blood transfusions are still used in certain military will require activation of the massive transfusion protocol
scenarios, the protocols were reoriented years ago toward (MTP). In broad terms, these cases represent only 2.6% of
the administration of specific blood components (RC, FFP or all serious traumatisms, but the associated mortality rate is
platelets).40 The aim of this strategy is to avoid transmissible so high that careful care and coordination with the blood
506 J.J. Egea-Guerrero et al.

banks is required.3 Since blood product availability upon Table 1 Probability of massive bleeding according to the
patient arrival in hospital must be considered, it is advisable Associated Severe Hemorrhage Score (TASH).
to implement an MTP in those centers that attend severe
trauma cases, in order to avoid unnecessary delays.1 As an Variable Value Score
example, in military scenarios, routine plasma thawing is Hemoglobin (g/dl) <7 8
carried out on a daily basis, or methods are adopted to <9 6
ensure prompt availability of FFP (universal donor plasma, <10 4
rapid thawing units, specific plasma formulations), in order <11 3
to optimize the management of these patients and try to <12 2
reach appropriate transfusion ratios.2,3,47 In this respect, Base excess (nM) <−10 4
different scores have attempted to predict patients with <−6 3
massive bleeding upon arrival in hospital, based on the <−2 1
use of clinical variables and basic explorations. A recent SBP (mmHg) <100 4
study comparing some of these scales has shown the Trauma <120 1
Associated Severe Hemorrhage Score (TASH) to offer the HR (bpm) >120 2
best correlation, making it possible to identify those Free intraabdominal Yes 3
patients who do not require activation of the MTP.43 Table 1 fluid/positive ECO-FAST
describes the TASH, as well as the probability of massive Extremities
bleeding according to the score reached.48 Clinically unstable 6
Other parameters may also be predictive of the need to pelvic fracture
activate the MTP, including the presence of hypocalcemia Open femoral 3
or the results of the ROTEM.34,38 In this latter case, the clot fracture/luxation
amplitude after 5 min (CA5) with a cutoff point of 35 mm Sex Male 1
allows us to identify those patients at risk of developing TASH score
massive bleeding after trauma.38
TASH score Probability of massive
transfusion
Prohemostatic drugs
1---8 <5%
To date, the most promising results referred to decreased 9 6%
trauma mortality are those published by the CRASH-2. This 10 8%
study evaluated the use of tranexamic acid (TXA) within the 11 11%
first 8 h after trauma, and documented a significant decrease 12 14%
in overall mortality after one month and in mortality due 13 18%
to massive bleeding versus placebo.49 The antifibrinolytic 14 23%
profile of the drug based on inhibition of the conversion of 15 29%
plasminogen to plasmin is the hypothesis that could best 16 35%
explain this decrease in mortality, taking into account as 17 43%
commented above the hyperfibrinolysis state that charac- 18 50%
terizes severe trauma.30 However, it should be noted that 19 57%
the use of TXA did not reduce the transfusion requirements 20 65%
of the patients. An analysis of the timing of TXA showed 21 71%
that administration in the first 3 h optimized the results 22 77%
obtained.49 Hence the early use of TXA is recommended 23 82%
by the trauma patient guides---the suggestion being to start 24 >85%
administration during pre-hospital patient management.4 ECO-FAST: focused assessment sonography in trauma; HR: heart
A cost-effectiveness analysis conducted by the National rate; SBP: systolic blood pressure.
Health Service on the use of TXA showed that utilization Reproduced from Maegele et al.48
of the drug resulted in a cost increment of only 64 USD for
each life saved.
It should be noted that there was no comparative other aspects.51 Some of these lines of research have already
increase in the incidence of ischemic adverse effects after been started in specific sub-populations of patients with TBI
the administration of TXA in over 20,000 patients.49 How- associated to intracranial bleeding injuries, based on the
ever, retrospective series posterior to the CRASH-2 have CRASH-3 study.52
described an increased risk of pulmonary and venous throm- Coagulopathy induced by trauma (CIT) is associated to
botic events, despite a documented decrease in mortality a decrease in factors I, II, V, VII, VIII, IX and X, mediated by
rate among polytraumatized patients.50 Recently, a series the activation of protein C.30 The most notorious decrease
of recommendations have been published that referred to corresponds to fibrinogen, and its levels are not seen to
future lines of research and their priority in relation to improve until damage control has been achieved.10.11,17,46
TXA. The purpose of these recommendations (explained in Retrospective studies have shown an increase in the fibrin-
Table 2) is to improve knowledge of the specific mecha- ogen:RC administration ratio to be correlated to patient
nism of action of the drug, and its safety profile, among survival.3,46 Administration can be made individually or
Resuscitative goals and new strategies in severe trauma patient resuscitation 507

Table 2 Recommended lines of investigation according to priority and gaps in knowledge regarding the use of tranexamic acid
(TXA).

Category Doubts and future lines of investigation

Priority 1
Safety Specifically investigate the increase in mortality risk due to bleeding in the group
of patients administered TXA beyond 3 h after trauma. Determine whether the
studies made showed an increase in the risk of deep venous thrombosis
and pulmonary thromboembolism.
Investigate thromboembolic risk during DCS.
Study the potential complications in patients in which TXA could be
contraindicated, including patients with brain trauma, and the impact upon the
development of seizure crises after surgery.
Evaluation of the patients in the clinical trials who died, to establish the
presence of microthrombi.
Animal models Development of animal models for studying the efficacy, safety and mechanisms
of action of TXA.
Additional tests of efficacy and Designing of clinical trials to define the efficacy of the drug in the military
definition of patients that may benefit and civil settings following the latest management recommendations.
from TXA
Mechanism of action Information on the mechanism of action in traumatic hemorrhage. Different
mechanisms have been proposed but have not been tested.
Efficacy and safety in head injuries Is the information on the potential efficacy and safety in patients
without associated lesions with traumatic/hemorrhagic brain injuries accurate?
Pre-hospital use (military scenario) Potential use in the pre-hospital setting, cases of deferred evacuation or
limitation of the supportive measures (no blood products or only plasma) and
modification of the dose/time window if immediate administration following
injury is possible.
Interactions with other fluids or drugs, impact upon storage on the battlefield.
Compatibility with the concept of remote guided damage control resuscitation.
Priority 2
Optimization of knowledge on the Efficacy and safety of TXA with administration at different timepoints after
time window for administration trauma. What is the best time for administration? When has the time window
been exceeded?
Use of TXA in combination with other How would its usefulness be improved if administered with other blood products?
blood products
Alternative administration routes Potential use of other administration routes (intravenous, oral, intraosseous,
etc.).
Priority 3
Interaction with the inflammatory and Identify inflammation and coagulation time patterns. Investigate how they are
coagulation cascades influenced by the administration of TXA in different moments.
Dosing All the available data are based on a single regimen. Could other dosing schemes
increase efficacy and safety? How are the pharmacokinetics affected in trauma?
Use with common resuscitation fluids Potential use of TXA in combination with new generation fluids.
Microcirculation Effects of TXA upon microcirculatory blood flow.
Interaction with other drugs Interaction with antithrombotic prophylaxis, prohemostatic drugs (such as
recombinant activated factor vii), antiseizure drugs and other substances.
TXA: tranexamic acid; DCS: damage control surgery.
Reproduced from Pusateri et al.51

associated to factors VIII and XIII in the form of a cryopre- of the reported experiences, guided by the ROTEM, have not
cipitate. Prescription is therefore advised according to the yet been validated.37
results of the ROTEM or when the detected plasma levels Lastly, the clinical trials that have evaluated the use
are below 1.5 g/l.37,40 of recombinant activated factor VII have evidenced a
The prothrombin complex allows us to administer large lesser need for blood products, as well as improvement of
doses of coagulation factors (II, VII, IX and X) in a small vol- bleeding in closed trauma.53 However, since there is no clear
ume, compared with FFP. It is clearly indicated in patients decrease in mortality, recombinant activated factor VII is not
under the effect of certain anticoagulant drugs.35 The rest regarded as a first line treatment option---its administration
508 J.J. Egea-Guerrero et al.

being restricted to compassionate use when other measures

Table 3 Situations amenable to damage control surgery.
prove ineffective.4
1. High-energy trauma with penetrating or blast injuries
Control of bleeding: damage control surgery 2. Coagulopathy present with impossibility of hemostasis
3. Major vascular damage
As has been commented above, the aim of damage con- 4. Multiple organ damage
trol surgery (DCS) is to minimize the surgical times, 5. Estimated surgical time for definitive repair > 90 min
since definitive management of the injuries from the start 6. Severity indexes such as ISS > 25
would worsen the situation of the patient and could even 7. Vital signs: SBP <70 mmHg, pH <7.1, Temp. <34 ◦ C
prove fatal, due to accelerated body heat loss caused by or lactate >6 mmol/l
exposure during surgery, the difficulty of providing ade- 8. Hemodynamic instability
quate volume replacement, and the increased presence of 9. Need for massive transfusion
acidosis and coagulopathy.2,5,6,54 The concept of DCS, ini- ISS: injury severity score; SBP: systolic blood pressure; Temp.:
tially referred to major abdominal injuries characterized temperature.
by uncontrollable bleeding and unstable pelvic fractures,
has been expanded to cover all types of injuries: renal,
retroperitoneal, vascular (of the extremities), thoracic, Patients requiring DCS are those who are at an increased
cerebral, etc. Hemostasis is usually achieved by arterial risk of death due to uncontrolled bleeding and in whom the
ligation, balloon tamponade catheters, vascular shunts or parameters and situations cited in Table 3 are observed.2,5
packing techniques.55 The resuscitation strategies are to be
maintained during DCS and should be considered as impor-
tant as anatomical repair itself.5 There is no concrete time Abdominal damage control surgery
window for definitive treatment of the injuries after DCS.
As can be seen in Fig. 2, management should be decided (a) Abdominal packing: This early laparotomy technique
according to the clinical condition of the patient, the type allows us to identify serious injuries and sources of bleeding.
of lesion and the planned DCS. As a result, it is often imple- When the surgical measures prove ineffective, packing may
mented beyond the classically proposed first 48 h.54,55 represent the first step within the concept of damage con-
It is recommended that the time elapsed between trauma trol. It can be used to compress liver rupture or directly
and surgery should be minimized in patients who require sur- apply pressure to bleeding points. The technique allows
gical control of bleeding.4 It is therefore crucial to establish future attempts to secure complete hemostasis through
an early diagnosis of such injuries. Apart from the traditional arteriography and/or application until CIT has been cor-
diagnostic methods, other complementary techniques such rected. In some cases aortic clamping and bypass may prove
as focused assessment sonography in trauma (ECO-FAST), necessary to reduce bleeding and redistribute the blood flow
spiral CAT, digital angiography, etc., not only help to locate to the heart and brain.4 Contamination can be adequately
the injuries but moreover are able to assess their extent and controlled by temporary ligation or exteriorization to the
impact with a view to afford a better surgical approach.56 skin, in the case of ruptured ureters or damaged hollow

Start damage control resuscitation. Evaluation of possible bleeding

Pre-hospital points. Control of external bleeding: use of tourniquets for limbs with
management massive bleeding, scalp suturing, etc. Shortening of time to arrival in
hospital in order to facilitate early bleeding control.
Hemostatic resuscitation

Re-evaluation and control of external bleeding, with identification of

Emergency
possible internal bleeding sites to decide surgery or interventional
room
radiology.

Perform procedures needed to control bleeding points, with

Operating immediate blood flow restoration and contamination control.
room

Patient stabilization, completion of the resuscitation process, warming,

Intensive
correction of acid-based imbalances and coagulopathy,
Care Unit
and optimization of ventilation and hemodynamic condition.

Definitive surgical repair, which should be done once full patient

Operating stabilization and resuscitation has been achieved (variable time
room window).

Figure 2 Chronogram and interventions in damage control surgery.

Resuscitative goals and new strategies in severe trauma patient resuscitation 509

organs, or by sealing intestinal damage without terminal using pelvic circumferential compression, excessive frac-
anastomoses. If abdominal wall closure is not possible, the ture reduction should be avoided, the points of support
organs are covered with sterile dressings that are affixed must be taken into account, and it must be remembered
to the wall margins, or using opened infusion solution bags that the nerve roots may be compressed in the case of
or Opsite (‘‘Vacpac’’).5 In these circumstances, laparotomy sacral fractures.
should be revised in under 48 h, once the bleeding risk c. Pelvic packing: In addition to closure and stabilization
has decreased.4 On occasion of the revision, the packing is of the pelvic fracture, the hematoma tamponade effect
removed and a thorough exploration of the zone is carried afforded by pre-, extra- or retroperitoneal packing may
out. reduce or arrest venous bleeding. Pelvic packing could
The main complication of the procedure is the devel- help control intrapelvic bleeding on an early basis and
opment of abdominal compartment syndrome, with an offer a better moment for more selective management
incidence of up to 15%, and which causes an important of the bleeding site. The technique can be combined
increase in mortality. The syndrome is a consequence of with posterior laparotomy if necessary. This can help
massive fluid support during resuscitation on one hand, and lessen the high mortality rate observed in patients with
of organ damage caused by the traumatism on the other. major pelvic injuries that require laparotomy as primary
Both mechanisms produce intestinal edema that gives rise intervention.4
to abdominal hypertension.7 d. Arteriography and embolization: This technique is cur-
(b) Arteriography and embolization: This is one of the rently accepted as an effective option for the control
most effective methods and allows minimally invasive con- of arterial bleeding when control has not been possi-
trol of bleeding in areas that are sometimes inaccessible ble through stabilization of the fracture. It is indicated:
or incoercible from the surgical perspective, and it can be (1) in the presence of hemodynamic instability or signs of
used as a therapeutic complement to packing.57 Emboliza- active bleeding, once bleeding on non-pelvic origins has
tion should be as distal as possible in the culprit artery, in been discarded; (2) when the CAT scan evidences con-
order to lessen the risk of tissue ischemia and lactic acidosis. trast extravasation; and (3) in patients over 60 years of
This technique is indicated: (1) in the presence of hemody- age with major pelvic fractures (vertical, ‘‘open book’’
namic instability or signs of active bleeding, once bleeding or ‘‘butterfly’’ fractures), independently of the hemody-
on non-abdominal origins has been discarded; and (2) when namic condition.59 Several authors indicate that survival
the CAT scan evidences contrast extravasation. can be improved by permissive hypotension until stabi-
At present, the possibility of equipping the trauma emer- lization of the fracture and/or arteriography becomes
gency operating room with an interventional radiology team possible.5,6
trained to act in resuscitation scenarios has been suggested.
This project, known as Resuscitation with angiography, per- The European guides recommend that patients with
cutaneous techniques and operative repair (RAPTOR), could pelvic ring disruption under conditions of hemorrhagic shock
increase the management options targeted to the bleeding should undergo immediate stabilization. Furthermore, in
site, minimizing delays and in-hospital patient transfer.58 the presence of hemodynamic instability despite adequate
However, while interesting, this initiative is currently dif- stabilization of the pelvic ring, preperitoneal packing is
ficult to apply in many hospitals. advised, with arteriography and embolization if needed,
and/or surgical control of the bleeding.4
Pelvic damage control surgery
Damage control surgery of the extremities
The pelvic volume increases significantly following unstable
pelvic fracture. This increase in volume favors bleeding and The use of a tourniquet is restricted to life-threatening
the massive hemorrhage caused by such fractures---thereby bleeding in patients with open wounds of the extremities,
contributing to hemorrhagic shock. In hemodynamically sta- until surgical resolution becomes possible. The use of this
ble patients with pelvic fracture, an abdominopelvic CAT technique has traditionally been described in the context of
scan is advised, due to the high incidence of associated catastrophes or military actions. The tourniquet should be
intraabdominal injuries.4,59 applied for as short a time as possible, with a suggested max-
imum of 2 h.4 Important fractures are mainly stabilized with
external fixators instead of definitive primary osteosynthe-
a. External fixation: The use of external fixation reduces
sis. The latter can be indicated at a later stage (4---14 days),
displacement of the fracture and thus lessens pelvic
once the patient has been stabilized.5
volume, but is unable to limit blood loss in patients
with active pelvic hemorrhage. An increased need for
blood product transfusions in the first 24---48 h has been Discussion
observed with external fixation in comparison with pelvic
circumferential compression, probably as a result of the Most of the objectives of resuscitation in trauma have been
promptness with which such compression is applied.59 addressed in the course of this study and are reflected in
b. Pelvic circumferential compression: Although the the- Table 4.
oretical models indicate that compression can help Although we have offered an in-depth exploration of
control bleeding, no subsequent studies have quantified the physiopathological knowledge referred to trauma, the
its true effect in terms of the hemodynamic stabilization review of the current literature cannot be considered com-
of unstable patients.59 It should be mentioned that when plete. The phenomena triggered after injury, and their
510 J.J. Egea-Guerrero et al.

Table 4 Objectives of resuscitation in the severe trauma Conflicts of interest

patient.
The authors declare that they have no conflicts of interest.
Variable Objective
Heart rate <100 bpm
Arterial pressure References
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