Anaes · Trauma and massive haemorrhage
Trauma and massive haemorrhage
Also known as Damage control resuscitation · Massive transfusion protocol · Permissive hypotension · Haemostatic resuscitation · Trauma-induced coagulopathy · The lethal triad · Damage control surgery · Tranexamic acid in trauma · Viscoelastic testing in trauma
Trauma and massive haemorrhage is the prototypical time-critical anaesthetic emergency and the commonest cause of preventable trauma death is uncontrolled haemorrhage. The modern response is damage control resuscitation — the integration of permissive hypotension (systolic 80 to 90 mmHg until haemostasis), haemostatic resuscitation with blood products in a 1:1:1 ratio rather than crystalloid, early tranexamic acid (1 g IV within 3 hours, CRASH-2), the activated massive transfusion protocol, damage control surgery (control bleeding, pack, temporary closure, ICU, definitive surgery when stable), and the active prevention of the lethal triad of acidosis, hypothermia and coagulopathy. The anaesthetist is central to the trauma team — the airway with cervical-spine precautions, the breathing, the circulation with haemorrhage control, and the coagulation.
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8 MCQs with explanations
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Meet the patient
A 24-year-old motorcyclist arrives in the resuscitation bay after a high-speed collision. He is pale, clammy, confused, his pulse is 130, blood pressure 78 palpable, and his abdomen is rigid. Two large-bore cannulae go in, the massive transfusion protocol is called, the pelvic binder goes on, and the theatre is warned. His systolic reads 78 — and the registrar reaches for a litre of Hartmann's. That is the first mistake.[1]
The questions that decide whether this man lives are the questions that decide every trauma haemorrhage: where is he bleeding, and can we stop it? Resuscitation without haemorrhage control is futile — the crystalloid dilutes the clot, the pressure dislodges it, and the lethal triad tightens its grip. Hold those two questions and the five pillars of damage control resuscitation below are obvious.[4]
You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Anaesthesia fellowship atlas.
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- [1]Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
- [2]Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203
- [3]Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition Crit Care, 2019.PMID 30917843
- [4]Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma J Trauma, 2007.PMID 17297317
- [5]Brohi K, Cohen MJ, Ganter MT, et al. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg, 2007.PMID 17457176
- [6]CRASH-3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial Lancet, 2019.PMID 31623894