RECOGNIZING PATIENTS WHO NEED (R)DCR

Goal

Recognize patients with traumatic hemorrhage who will benefit from implementing DCR early to decrease mortality.

Initial Survey:

Recognize hemorrhagic shock based on rapid examination and recognition of severe injury pattern.

- Injury pattern consistent with massive hemorrhage:
  - Above-the-knee traumatic amputation, especially if associated with pelvic injury
  - Proximal, bilateral, or multiple amputations (including mangled extremity)
  - Clinically obvious penetrating injury to chest or abdomen
  - Uncontrolled truncal or junctional bleeding
  - Uncontrolled major bleeding secondary to large soft-tissue injuries
- Severe trauma with altered mental status (in the absence of brain injury) and/or weak or absent radial pulse.9

If initial survey does not indicate severe blood loss, continue assessment, check vital signs, and assess for signs of shock. Recognize hemorrhagic shock on the basis of presence of severe traumatic injury associated with the following:

- Systolic blood pressure (SBP) less than 100mmHg
- Pulse greater than 100 bpm
- Clinical signs of shock, such as cool extremities, delayed capillary refill
- Clinical signs of coagulopathy (e.g., thin, nonclotting bleeding from multiple sites, bleeding from minor wounds such as intravenous [IV] or intraosseous [IO] sites)

Advanced Capabilities

When additional laboratory capability and/or ultrasound are available, confirm evidence of hemorrhagic shock using laboratory and/or imaging studies. Do not delay initiating DCR if hemorrhagic shock is clinically suspected: Begin treating immediately once hemorrhagic shock is suspected.

Predictors associated with massive transfusion (i.e. more than 10 units of blood in the first 24 hours) may help identify patients who will require massive transfusion. The more predictors present, the higher the risk of massive transfusion.13–22

- Penetrating mechanism
- Positive focused assessment with sonography for trauma (FAST) examination (especially if two or more regions are positive)
- Lactate concentration greater than 4mmol/L on presentation
- Base deficit more than 6mEq/L (base excess less than −6mEq/L)
- pH less than 7.25
- International normalized ratio (INR) 1.5 or greater