|Home | About | Journals | Submit | Contact Us | Français|
Overall, injuries are the third leading cause of death in the United States, but they affect the younger and most productive segment of our society disproportionately. According to the National Center for Health Statistics, injuries are the number one cause of death and disability under age 44, and more Americans between the ages of 1–34 years are killed by injuries than by all other diseases combined1. The financial impact of injuries is staggering- 50 million injuries that required medical treatment in 2000 will ultimately cost the US society $406 billion, including $80.2 billion in medical care costs and $326 billion in lost productivity2.
Analysis of epidemiological data from large trauma centers reveals consistent patterns of death 3–7. Up to half of the deaths occur prior to arrival in a hospital as a result of massive blood loss or central nervous system (CNS) damage. Compared to severe CNS damage, death resulting from bleeding is potentially preventable, and life saving efforts focus on early control of bleeding and adequate resuscitation. Unfortunately, conventional resuscitation methods often exacerbate the underlying cellular injury8. Of the patients that are transported to the hospital, the majority (70–80%) dies within the first 24–48 hours, with a much smaller percentage (<10%) succumbing to late death as a result of sepsis and organ failure. As hemorrhage-related deaths primarily occur in the first six hours after injury5, early delivery of high quality care is of critical importance. Despite hemorrhage being a common problem, the optimal resuscitative strategy remains controversial, with vigorous debates about the type of fluid, volume, rate, route of administration, and end points of resuscitation. This review highlights recent advances in resuscitation strategies as our understanding of the body’s response to hemorrhage and resuscitation has evolved.
One situation where there is still need for a low-volume, rapid, and effective treatment for coagulopathy is in elderly trauma patients on warfarin, especially after TBI. Rapid infusion of required plasma volume (15–20 ml/kg) is often not possible due to multiple comorbid problems (e.g. congestive heart failure, pulmonary edema, renal failure) in these patients. Prothrombin complex concentrates (PCC) provide a rapid and effective method for delivering vitamin K dependent clotting factors to correct the coagulopathy. A variety of PCC products has been around for nearly 30 years, and they all contain factors II, IX, and X with variable amounts of VII and anti-coagulant proteins C and S105. Early studies have shown PCC to be effective in rapidly reversing anticoagulation (n=50), to allow surgical procedures or control post-operative bleeding without complications106. RCTs are ongoing in patients that require correction of coagulopathy for surgery or for TBI, where PCC are being compared to standard treatment (FFP of vitamin K). Currently, no data exists to support their use in massively bleeding poly-trauma patients without a history of warfarin use.
Hemorrhage is the leading cause of potentially preventable deaths in the battlefield and in civilian trauma. Prompt control of hemorrhage and adequate resuscitation are considered critical in the management of these patients. With a better understanding of shock, it is not surprising that our treatment strategies have also evolved177. This transformation has been especially dramatic over the last decade- large volume crystalloids resuscitation is out, whereas low-volume resuscitation has become the new norm. Drugs that can augment tissue perfusion or selectively create a “pro-survival phenotypes” are being aggressively investigated. Custom designed protocols are preferred over generic resuscitation efforts, and permissive hypotension is the new buzz word.
Emerging data, basic science and clinical, have challenged the dogma of large volume crystalloid resuscitation, and our clinical paradigms are in a state of flux (table 2). Resuscitation strategies being utilized by the US military in Iraq and Afghanistan have already changed: resuscitation is selective, low volume, aims for practical endpoints (e.g. pulse and mental status), and fluids with logistical advantages (e.g. hetastarch) are preferred. Also, early hemorrhage control is prioritized over aggressive fluid resuscitation. Although civilian trauma centers don’t face the same logistical limitations as the military hospitals, they have also adopted a similar approach. It is difficult to determine the direct impact of these new strategies on outcomes, but it is very interesting to note that post-resuscitation complications such as ARDS are becoming increasingly rare in this new era of judicial resuscitation (4 fold decrease over 5 years) 178.
The concept of “damage control resuscitation” with early use of blood components in appropriate patients has been widely adopted over the last few years. Trauma surgeons are avoiding crystalloids and using blood products early during the resuscitation of severely injured patients, not only to avoid the complications of crystalloids but also to maintain better oxygen delivery and normal coagulation status. We still don’t know the optimal ratio of component therapy, but ongoing studies should provide the answer in the near future. Along the same lines, efforts to preserve blood products for pre-hospital use are being heavily funded, and shelf-stable plasma is now ready for clinical trial. Finally, novel resuscitation techniques, such as therapeutic hypothermia and cyto-protective drugs, may soon become part of our armamentarium. These are exciting times, with battlefield challenges along with robust funding by the Department of Defense fueling rapid advances. It can be argued that the only winner in any war is the field of trauma care itself, and the current conflict is no exception179. We may not have all the right answers yet, but the ongoing research has the potential to revolutionize the care of the critically injured patients.
Dr. Alam would like to acknowledge research support provided by numerous grants by the Office of Naval Research, US Army Medical Research and Materiel Command, Defense Advanced Research Projects Agency, and National Institutes of Health. The opinions and assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the views of the Department of Defense at large.
To provide a mechanism to facilitate replacement of massive blood loss with appropriate blood and blood products within a clinically significant timeframe.
Application of the Massive Transfusion Protocol requires a multidiscipline/multiservice practice based on clinical judgment and decision-making, clear communication patterns and strong cooperative efforts.
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.