Trauma Resuscitation – An Update for 2012

This is a video of a talk I gave to the docs and paramedics at the Sydney HEMS Clinical Governance Day recently.  It’s based around a couple of recent review articles unearthed by the ever searching, apparently never sleeping, Cliff Reid (@cliffreid).

Here are links to some of the articles mentioned in the talk.  It’s just over 30 mins, so a bit longer than a podcast should be, sorry.   On the upside I took care not to include a single bullet point, as we all know bullets are for killing people you don’t like, and I have enough of those, so I don’t need to be wasting bullets on keynote presentations.

1. Scand J Trauma Resusc Emerg Med. 2012 Sep 18;20(1):68. [Epub ahead of print]

Critical care considerations in the management of the trauma patient following
initial resuscitation.

Shere-Wolfe RF, Galvagno SM Jr, Grissom TE.

BACKGROUND: Care of the polytrauma patient does not end in the
operating room or resuscitation bay. The patient presenting to the intensive care
unit following initial resuscitation and damage control surgery may be far from stable with ongoing hemorrhage, resuscitation needs, and injuries still requiring definitive repair. The intensive care physician must understand the respiratory,  cardiovascular, metabolic, and immunologic consequences of trauma resuscitation and massive transfusion in order to evaluate and adjust the ongoing resuscitative needs of the patient and address potential complications. In this review, we address ongoing resuscitation in the intensive care unit along with potential complications in the trauma patient after initial resuscitation. Complications such as abdominal compartment syndrome, transfusion related patterns of acute lung injury and metabolic consequences subsequent to post-trauma resuscitation are presented. 
METHODS: A non-systematic literature search was conducted using
PubMed and the Cochrane Database of Systematic Reviews up to May 2012. RESULTS AND CONCLUSION: Polytrauma patients with severe shock from hemorrhage and massive
tissue injury present major challenges for management and resuscitation in the intensive care setting. Many of the current recommendations for "damage control
resuscitation" including the use of fixed ratios in the treatment of trauma
induced coagulopathy remain controversial. A lack of large, randomized,
controlled trials leaves most recommendations at the level of consensus, expert opinion. Ongoing trials and improvements in monitoring and resuscitation technologies will further influence how we manage these complex and challenging

PMID: 22989116  [PubMed - as supplied by publisher]

1. Anesth Analg. 2012 Dec;115(6):1326-33. doi: 10.1213/ANE.0b013e3182639f20. Epub 2012 Jul 4. 
Review article: update in trauma anesthesiology: perioperative resuscitation management. Tobin JM, Varon AJ. University of Maryland/R Adams Cowley Shock Trauma Center, 22 South Greene St., T1R77, Baltimore, MD 21201. 
The management of trauma patients has matured significantly since a systematic approach to trauma care was introduced nearly a half century ago. The resuscitation continuum emphasizes the effect that initial therapy has on the outcome of the trauma patient. The initiation of this continuum begins with prompt field medical care and efficient transportation to designated trauma centers, where lifesaving procedures are immediately undertaken. Resuscitation with packed red blood cells and plasma, in parallel with surgical or interventional radiologic source control of bleeding, are the cornerstones of trauma management. Adjunctive pharmacologic therapy can assist with resuscitation. Tranexamic acid is used in Europe with good results, but the drug is slowly being added to the pharmacy formulary of trauma centers in United States. Recombinant factor VIIa can correct abnormal coagulation values, but its outcome benefit is less clear. Vasopressin shows promise in animal studies and case reports, but has not been subjected to a large clinical trial. The concept of "early goal-directed therapy" used in sepsis may be applicable in trauma as well. An early, appropriately aggressive resuscitation with blood products, as well as adjunctive pharmacologic therapy, may attenuate the systemic inflammatory response of trauma. Future investigations will need to determine whether this approach offers a similar survival benefit. 
PMID: 22763906 [PubMed - in process]
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