Resuscitation

NOTE: See Damage Control Resuscitation CPG7

- Ratios of fresh frozen plasma (FFP): packed red blood cells (PRBC) approaching 1:1 have been demonstrated to confer a survival benefit in military and civilian trauma patients.19, 20 While the ideal ratio of FFP: PRBC remains somewhat controversial, it is fair to say early administration of plasma and platelets is appropriate for the trauma patient in extremis.21 When available, use cold stored whole blood. Fresh whole blood may also be safely used. A more exhaustive discussion of damage control resuscitation is found elsewhere in the CPGs and is recommended reading for this subject. Communication with the surgical team regarding the progress of the resuscitation and the stage of the surgery is an important factor in overall success.
- TXA is a potent synthetic lysine derivative that functions as an anti-fibrinolytic. Administration of 2 gm of TXA IV/IO ASAP or within 3 hours of injury has been demonstrated to improve survival in a highly powered, randomized trial of international trauma patients.22 A survival advantage was also demonstrated with the use of TXA in military trauma.23 A recent analysis of prehospital dosing strategies for TXA in moderate to severe TBI found a significantly improved neurologic function at 6 months with a 2 gm bolus given prehospital compared to a 1 gm bolus + 1 gm infusion or placebo for the subset of patients with confirmed intracerebral hemorrhage, and no difference in survival or complications for either dose or placebo for all patients treated based on prehospital Glasgow Coma Scale (GCS) 3-12.24 In other work, when prehospital TXA was administered within 1 hour of injury to patients in severe shock there was a 30 day mortality benefit.25 More detailed analysis of timing and dosing regimens is on-going, but in the meantime it is safe to administer an initial 2 gm bolus of TXA
- Hydrocortisone is a potent mineralocorticoid which can augment blood pressure during shock states when the hypothalamic–pituitary–adrenal (HPA) axis is suppressed and unable to mount an effective stress response. Administration of hydrocortisone 100 mg can improve vasopressor responsiveness in critically ill trauma patients.26,27
- Hypocalcemia must be avoided in massive blood transfusion. Hypocalcemia is often due to chelation of calcium by the citrate preservative in stored blood. Trauma patients can be hypocalcemic even prior to blood product administration.28 Severe hypocalcemia (iCa <0.9), has been associated with higher lactate, lower pH and worsened mortality. 29 30 Administration of 1 gm calcium-can correct this potentially life-threatening hypocalcemia, and the hypotension associated with it. Consider following ionized calcium levels with POC chemistry analysis. If this in unavailable, then consider empiric administration of 1gm calcium chloride after each 4th unit of blood.31
- Use of vasopressors in trauma is generally associated with higher mortality.32 In one analysis evaluating trauma patients who received vasopressor support, vasopressin was found to be the only vasopressor in which the 95% confidence interval for mortality crossed unity, suggesting non-significance.33 Vasopressin was further evaluated by in a randomized controlled trial in which trauma patients received a vasopressin bolus followed by an infusion. The vasopressin group required fewer blood products, had similar mortality and complication rates.34 In cases of refractory hypotension, a vasopressin bolus (2-4 units) followed by infusion (0.04 U/min) can be given in concert with aggressive blood product administration.
- Timely administration of antibiotics can decrease the incidence of post-operative infections and is part of the anesthetic resuscitation. Consider agents that will be effective against skin flora (Gram positive organisms) or, in the event of bowel injury, gastrointestinal flora (anaerobes and Gram negative organisms). The Infection Prevention in Combat-Related Injuries CPG identifies the optimal antibiotics for multiple clinical scenarios.