Trauma and massive haemorrhage

Your progress

Saved on this device.

Target exams

Red flags

• Uncontrolled haemorrhage is the leading cause of PREVENTABLE trauma death, and the lethal triad of acidosis, hypothermia and coagulopathy is the self-perpetuating death spiral. The young fit patient compensates until a third of the blood volume is gone — a normal pulse and blood pressure do NOT exclude major blood loss. Trust the mechanism, the continuing losses, the rising lactate, the worsening base excess and the clinical trajectory, never the first set of vital signs.
• Permissive hypotension (systolic 80 to 90 mmHg, or a mean arterial pressure of 65 mmHg) is maintained UNTIL SURGICAL HAEMOSTASIS to reduce clot disruption and ongoing blood loss. It is CONTRAINDICATED in the traumatic brain injury (the cerebral perfusion pressure must be defended), the spinal cord injury, and the elderly or cardiovascularly-compromised patient.
• Tranexamic acid 1 g IV over 10 minutes then 1 g over 8 hours reduces all-cause mortality and bleeding death when given within 3 hours of injury (CRASH-2). After 3 hours it increases mortality. Give it EARLY — ideally pre-hospital or the moment haemorrhage is recognised.
• Resuscitate with BLOOD PRODUCTS not crystalloid. Crystalloid dilutes clotting factors and platelets, causes acidosis, and induces the lethal triad. The empirical ratio is 1:1:1 packed red cells to fresh frozen plasma to platelets, fine-tuned by viscoelastic testing. Give calcium — the citrate in transfused products chelates it and hypocalcaemia worsens coagulation, contractility and vascular tone.
• The trauma airway is high-risk: the cervical spine is at risk, the stomach is full, there is blood and debris, and there may be a head injury. A rapid sequence induction with manual in-line stabilisation, videolaryngoscopy and a front-of-neck backup is standard. The patient with a combined TBI is intubated EARLY and kept normoxic and normocapnic.