Resuscitation and transfusion principles for traumatic hemorrhagic shock.
The transfusion approach to massive hemorrhage has continually evolved since it began in the early 1900s. It started with fresh whole blood and currently consists of virtually exclusive use of component and crystalloid therapy. Recent US military experience has reinvigorated the debate on what the most optimal transfusion strategy is for patients with traumatic hemorrhagic shock. In this review we discuss recently described mechanisms that contribute to traumatic coagulopathy, which include increased anti-coagulation factors and hyperfibrinolysis. We also describe the concept of damage control resuscitation (DCR), an early and aggressive prevention and treatment of hemorrhagic shock for patients with severe life-threatening traumatic injuries. The central tenants of DCR include hypotensive resuscitation, rapid surgical control, prevention and treatment of acidosis, hypothermia, and hypocalcemia, avoidance of hemodilution, and hemostatic resuscitation with transfusion of red blood cells, plasma, and platelets in a 1:1:1 unit ratio and the appropriate use of coagulation factors such as rFVIIa and fibrinogen-containing products (fibrinogen concentrates, cryoprecipitate). Fresh whole blood is also part of DCR in locations where it is available. Additional concepts to DCR since its original description that can be considered are the preferential use of "fresh" RBCs, and when available thromboelastography to direct blood product and hemostatic adjunct (anti-fibrinolytics and coagulation factor) administration. Lastly we discuss the importance of an established massive transfusion protocol to rapidly employ DCR and hemostatic resuscitation principles. While the majority of recent trauma transfusion papers are supportive of these general concepts, there is no Level 1 or 2 data available. Taken together, the preponderance of data suggests that these concepts may significantly decrease mortality in massively transfused trauma patients.
Spinella
Philip C
PC
University of Connecticut, Pediatric Intensivist, Department of Pediatrics, Department of Surgery, Connecticut Children's Medical Center, Hartford, CT 06106, USA. pspinella@ccmckids.org
Holcomb
John B
JB
D001803:Blood Transfusion; D006801:Humans; D012151:Resuscitation; D012771:Shock, Hemorrhagic / Q000628:therapy*; D012774:Shock, Traumatic / Q000628:therapy*
J Trauma. 2003 Jul;55(1):39-44
12855879
Anesth Analg. 1968 Sep-Oct;47(5):506-8
5691690
J Trauma. 2008 Aug;65(2):279-82; discussion 282-4
18695462
J Trauma. 2007 Feb;62(2):307-10
17297317
J Trauma. 1995 Feb;38(2):185-93
7869433
Transfusion. 2003 Nov;43(11):1622-33
14617324
N Engl J Med. 1994 Oct 27;331(17):1105-9
7935634
Crit Care. 2010;14(2):R57
20377853
J Trauma. 2009 Jun;66(6):1509-15; discussion 1515-7
19509608
J Trauma. 2011 Aug;71(2 Suppl 3):S318-28
21814099
J Trauma. 2008 Jun;64(6):1459-63; discussion 1463-5
18545109
N Engl J Med. 2006 Jun 15;354(24):2564-75
16714767
J Trauma. 2003 May;54(5 Suppl):S46-51
12768103
Blood. 2005 Mar 15;105(6):2266-73
15572582
Transfusion. 2006 Aug;46(8):1279-85
16934060
Crit Care Med. 2008 Jul;36(7 Suppl):S267-74
18594252
Ann Surg. 1986 Jan;203(1):40-8
3510591
Shock. 2006 Oct;26(4):396-401
16980888
J Trauma. 2009 Feb;66(2):346-52
19204506
Transfusion. 2007 Apr;47(4):593-8
17381616
J Trauma. 2003 May;54(5 Suppl):S110-7
12768112
Anesth Analg. 2006 Feb;102(2):347-51
16428520
Transfusion. 2006 May;46(5):685-6
16686833
J Trauma. 1997 Apr;42(4):716-20; discussion 720-2
9137263
Cochrane Database Syst Rev. 2012 Mar 14;(3):CD005011
22419303
Crit Care Med. 2003 Dec;31(12 Suppl):S687-97
14724467
J Trauma. 1997 May;42(5):857-61; discussion 861-2
9191667
Ann Surg. 2007 Jun;245(6):986-91
17522526
J Trauma. 2008 Apr;64(4):1010-23
18404069
Blood. 1991 Mar 1;77(5):930-6
1995100
Crit Care Med. 2007 Nov;35(11):2576-81
17828033
J Trauma. 2008 Feb;64(2 Suppl):S64-8
18376174
Shock. 2004 Apr;21(4):291-9
15179127
Ann Surg. 2008 Oct;248(4):578-84
18936570
Can J Anaesth. 1998 Oct;45(10):993-6
9836037
Crit Care Med. 2008 Jul;36(7 Suppl):S340-5
18594261
Shock. 2000 Jan;13(1):29-33
10638666
J Trauma. 2009 Apr;66(4 Suppl):S77-84; discussion S84-5
19359974
Ann Surg. 2003 Nov;238(5):641-8
14578723
J Trauma. 2008 Oct;65(4):748-54
18849786
Transfus Med. 2007 Jun;17(3):182-6
17561859
Crit Care Med. 1997 May;25(5):726-32
9187588
Transfus Med Rev. 2003 Jul;17(3):223-31
12881783
Vox Sang. 2008 Aug;95(2):112-9
18557827
Blood Coagul Fibrinolysis. 2002 Jun;13(4):309-13
12032396
J Trauma. 1995 Nov;39(5):955-62
7474014
J Trauma. 2007 Jan;62(1):142-6
17215745
Vox Sang. 2009 Feb;96(2):93-103
19152602
Transfusion. 2009 Jan;49(1):34-9
18954393
Pediatr Crit Care Med. 2009 Mar;10(2):e22-6
19265363
Am Surg. 2008 Dec;74(12):1159-65
19097529
Arch Surg. 1999 Sep;134(9):964-8; discussion 968-70
10487591
J Trauma. 2005 Jul;59(1):8-15; discussion 15-8
16096533
J Trauma. 2009 Jan;66(1):41-8; discussion 48-9
19131804
Am J Physiol Endocrinol Metab. 2005 Nov;289(5):E930-4
15956050
J Am Coll Surg. 2007 Oct;205(4):541-5
17903727
J Trauma. 2005 Mar;58(3):475-80; discussion 480-1
15761339
J Trauma. 2006 Jun;60(6 Suppl):S12-9
16763475
J Trauma. 2007 Oct;63(4):805-13
18090009
J Trauma. 2009 Apr;66(4 Suppl):S69-76
19359973
J Trauma. 2006 Jun;60(6 Suppl):S91-6
16763487
Am J Surg. 2005 Sep;190(3):479-84
16105540
Transfusion. 2004 Jun;44(6):809-13
15157244
J Trauma. 2008 Sep;65(3):535-43
18784565
Ann Surg. 2008 Sep;248(3):447-58
18791365
J Trauma. 2006 Jun;60(6 Suppl):S46-50
16763481
Anesthesiology. 1996 Mar;84(3):732-47
8659805
J Vet Intern Med. 2008 Mar-Apr;22(2):357-65
18346141
J Trauma. 2009 Jun;66(6):1616-24
19509623
J Trauma. 2009 Feb;66(2):358-62; discussion 362-4
19204508
Can J Anaesth. 1997 Dec;44(12):1256-61
9429042
J Thorac Cardiovasc Surg. 2008 Dec;136(6):1442-9
19114187
J Surg Res. 2002 Jan;102(1):6-12
11792145
J Trauma. 2008 Oct;65(4):755-64; discussion 764-5
18849787
J Am Coll Surg. 2004 Jan;198(1):20-6
14698307
Crit Care Med. 2005 Jan;33(1):39-45; discussion 238-9
15644646
Am Surg. 1998 Oct;64(10):950-4
9764699
J Trauma. 2007 Jan;62(1):112-9
17215741
Transfusion. 2006 Nov;46(11):2014-27
17076859
J Trauma. 2003 Apr;54(4):663-9; discussion 669-70
12707527
Surg Clin North Am. 2007 Feb;87(1):55-72, vi
17127123
Mil Med. 1984 Feb;149(2):55-62
6427656
Transfusion. 2008 Aug;48(8):1763-5
18482190
J Trauma. 2006 Jul;61(1):99-106
16832255
J Trauma. 2003 Jan;54(1):66-70; discussion 70-1
12544901
J Trauma. 1996 Apr;40(4):501-10; discussion 510-2
8614027
J Trauma. 2007 Jun;62(6):1352-9; discussion 1359-61
17563647
Semin Hematol. 2004 Jan;41(1 Suppl 1):140-4
14872435
Arch Surg. 2002 Jun;137(6):711-6; discussion 716-7
12049543
Br J Anaesth. 2005 Aug;95(2):172-7
15923269
J Trauma. 2008 Feb;64(2 Suppl):S79-85; discussion S85
18376176
J Trauma. 2006 Jun;60(6):1228-36; discussion 1236-7
16766965
J Trauma. 2008 Feb;64(2 Suppl):S57-63; discussion S63
18376173
J Trauma. 2008 Aug;65(2):272-6; discussion 276-8
18695461
Curr Opin Crit Care. 2006 Dec;12(6):575-83
17077690
J Trauma. 2008 May;64(5):1211-7; discussion 1217
18469643
J Trauma. 2003 May;54(5):848-59; discussion 859-61
12777898
Crit Care Clin. 2004 Apr;20(2):255-68
15135464
J Trauma. 2009 Mar;66(3):693-7
19276739
Am J Surg. 1999 Dec;178(6):570-2
10670874
Ann Surg. 1945 Jun;121(6):769-92
17858614
J Trauma. 2001 Mar;50(3):426-31; discussion 432
11265021
J Trauma. 2003 Jun;54(6):1127-30
12813333
J Trauma. 2008 Aug;65(2):261-70; discussion 270-1
18695460
Shock. 2006 Aug;26(2):115-21
16878017
Chest. 2005 Jan;127(1):295-307
15653997
N Engl J Med. 1999 Feb 11;340(6):409-17
9971864
J Trauma. 2008 Feb;64(2 Suppl):S69-77; discussion S77-8
18376175
Surgery. 1985 Oct;98(4):836-44
4049256
J Trauma. 2008 Feb;64(2):286-93; discussion 293-4
18301188
J Trauma. 2008 Nov;65(5):986-93
19001962
J Trauma. 2008 Sep;65(3):527-34
18784564
J Trauma. 2008 May;64(5):1177-82; discussion 1182-3
18469638
Crit Care Med. 2006 May;34(5 Suppl):S170-3
16617262
J Trauma. 2003 Mar;54(3):454-63
12634523
Am J Surg. 2005 Sep;190(3):456-62
16105536
Am J Surg. 2009 May;197(5):565-70; discussion 570
19393349
J Trauma. 2006 Jun;60(6 Suppl):S59-69
16763483