Third Priority: Controlled Resuscitation

Consider the following before initiating volume resuscitation. The patient who is bleeding may not appear to be in shock, and the patient who is in shock may not be actively bleeding. Your goal is to not only to identify shock/occult shock, but also to identify active bleeding and obstructive and neurogenic shock. Again, consider a volume challenge to assess for active occult hemorrhage. If there is no response to 250 mL of crystalloid, consider other causes of shock.

Controlled resuscitation (previously termed “permissive hypotension”) represents a paradigm shift in trauma resuscitation.¹⁰ Large volumes of crystalloid may contribute to the trauma “triangle of death” (metabolic acidosis, hypothermia, and coagulation derangements).¹¹ While there are fairly well studied resuscitation targets in the first few hours of trauma resuscitation (eg, urine output, lactate clearance, base deficit), there is little evidence to guide us in the first 15 minutes of trauma resuscitation.¹² If there is a delay in starting blood transfusion in a patient presumed to have hemorrhagic shock, consider only small boluses of crystalloid (ie, 250 mL), just enough to maintain adequate tissue perfusion (peripheral pulses present in blunt trauma or central pulses in penetrating injury) and maintain a SBP ≥70. For most trauma patients, consider targeting this SBP throughout your resuscitation. This controlled resuscitation is a reasonable early resuscitation target. One prospective randomized controlled trial comparing controlled resuscitation with usual care showed a number needed to treat of 11 for in-hospital mortality.¹⁰ Keep in mind that the elderly patient, the patient with uncontrolled hypertension at baseline, the patient with a major head injury, and the patient with neurogenic shock may require adjustments to their SBP target.

Fourth Priority: Consideration for Massive Transfusion

Here is a suggested approach to decision-making around massive transfusion protocol (MTP) activation in trauma patients. It is important to integrate your clinical judgment and mechanism of injury, as well as patient age, presence of anticoagulant medication, and comorbidities into your decision-making.¹³

Step 1: If the patient is in an obvious shock state, has an Assessment of Blood Consumption (ABC) score ≥2, a shock index of >1, or delta shock index of ≥0.1, activate the MTP.^14-16

Step 2: If none of these are present, consider resuscitation intensity.^17,18 Patients who require four units of any combination of crystalloids or blood products to maintain adequate perfusion are considered to have high resuscitation intensity, which predicts higher mortality, and should be considered for MTP.

Summary

Next time you’re faced with a polytrauma patient, consider resequencing the trauma resuscitation by managing massive external hemorrhage and active/dynamic airway first. Then concentrate on hemodynamic optimization before definitive airway management in those patients without active/dynamic airways. Identify occult shock using a shock index of >1, a delta shock index of ≥0.1, the lowest BP recorded, FAST/IVC assessment, and/or a fluid challenge with clinical exam. Consider the patient’s age, blood pressure medications, and baseline blood pressure in assessing for the presence of occult shock, interpreting the shock index, and in deciding to activate your MTP. Large volumes of crystalloid may lead to the “triangle of death;” your goal should be to minimize crystalloids. Controlled resuscitation to a target SBP of ≥70 is reasonable in most young, otherwise healthy trauma patients presumed to be in hemorrhagic shock. Finally, use clinical judgment, mechanism of injury, patient age and comorbidities, shock index, and resuscitation intensity to help you decide when to activate the MTP.