While advanced trauma life support has traditionally emphasized the “ABC” (airway, breathing, and circulation) approach for all trauma patients, a more nuanced approach is required in order to avoid catastrophic outcomes in the early resuscitation of the polytrauma patient.
First Priorities in Trauma Resuscitation
Focus should be on physiologic priorities.1 The most severe, life-threatening injuries should be temporized first. The two categories of immediate life threats in trauma include massive external hemorrhage, temporized by local pressure and/or tourniquet, and critical airway compromise. Critical airway compromise can be further divided into critical/refractory hypoxia, which is less than 90 percent oxygen saturation despite optimized noninvasive ventilation; and dynamic airway, which is evolving disruption of the airway anatomy and/or head and neck injuries that are expected to worsen over the next few minutes.
Second Priorities: “C” Before “A”
After the immediate life threats of massive external hemorrhage and critical airway compromise have been addressed, resuscitation should then focus on hemodynamic optimization before definitive airway management. Endotracheal intubation causes an increase in intrathoracic pressure, resulting in a decrease in right atrial pressure, which negatively impacts both hemorrhagic and obstructive shock. Pre-intubation hypotension is a significant risk factor for post-intubation cardiac arrest.2 Hence, the adage, “Resuscitate before you intubate” in volume-depleted patients. Procedures to relieve obstructive shock, such as bilateral finger thoracostomies and thoracotomy, should be considered prior to endotracheal intubation. A similar “CABC” (circulation, airway, breathing, and circulation) approach has been adapted in the cardiac arrest literature.
Step-wise Approach to Identify Occult Shock
The patient who rolls into your resuscitation room after a worrisome mechanism and with a mean arterial pressure of 30 is in an obvious shock state. However, many trauma patients present in occult shock. Under-recognition of occult shock in trauma is associated with poor patient outcomes.3 The following step-wise approach will minimize your chances of missing occult shock.
- Calculate the shock index (heart rate divided by systolic blood pressure [SBP]) and/or delta shock index.4,5 If the shock index is >1 or the delta shock index ≥0.1, assume occult shock is present.
- Assess the lowest blood pressure (BP) measured and trend the BP over time; if isolated or persistent SBP <110, assume occult shock.6 A single low BP either in the field or in the emergency department has been shown to predict poor outcomes in trauma patients.
- Positive focused assessment with sonography in trauma (FAST) with flat inferior vena cava (IVC)? Assume occult shock.
- Consider a volume challenge to assess for active occult hemorrhage by administering 250 mL of crystalloid under pressure followed by assessment for signs of perfusion. If a patient transiently responds to 250 mL of crystalloid, you may assume active occult hemorrhage.
A shock index of >1 or a delta shock index of ≥0.1 is a sign of occult shock and is predictive of post-intubation hypotension, transfusion requirements, injury severity, and mortality.4,5 A practical tip to help identify occult shock is to ask EMS not only what the most recent BP was, but what the lowest BP they recorded was. A single drop in BP in the field or in the emergency department is predictive of the need for surgical intervention and mortality.7 One common pitfall in diagnosing shock is ignoring pre-hospital hypotension that normalizes without intervention. An isolated decrease in SBP <105 mmHg is associated with a 12-fold increase in the need for immediate therapeutic intervention.8
The shock index is unreliable in patients with altered physiologic compensation such as elderly patients, undertreated hypertension, and patients taking medications that lower the heart rate, such as beta-blockers.9 In these patients, consider the delta shock index, which may be a more reliable indicator of occult shock.5
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.
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.
Special thanks to Andrew Petrosoniak, MD, Chris Hicks, MD, and Kylie Bosman, MD, for their expert contributions to the EM Cases podcast that inspired this article.
- Petrosoniak A, Hicks C. Resuscitation resequenced: a rational approach to patients with trauma in shock. Emerg Med Clin North Am. 2018;36(1):41-60.
- Kim WY, Kwak MK, Ko BS, et al. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One. 2014;9(11):e112779.
- Blow O, Magliore L, Claridge JA, et al. The golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcome from major trauma. J Trauma. 1999;47(5):964-969.
- King RW, Plewa MC, Buderer NM, et al. Shock index as a marker for significant injury in trauma patients. Acad Emerg Med. 1996;3(11):1041-1045.
- Joseph B, Haider A, Ibraheem K, et al. Revitalizing vital signs: the role of delta shock index. Shock. 2016;46(3 Suppl 1):50-54.
- Codner P, Obaid A, Porral D, et al. Is field hypotension a reliable indicator of significant injury in trauma patients who are normotensive on arrival to the emergency department? Am Surg. 2005;71(9):768-771.
- Seamon MJ, Feather C, Smith BP, et al. Just one drop: the significance of a single hypotensive blood pressure reading during trauma resuscitations. J Trauma. 2010;68(6):1289-1294.
- Lipsky AM, Gausche-Hill M, Henneman PL, et al. Prehospital hypotension is a predictor of the need for an emergent, therapeutic operation in trauma patients with normal systolic blood pressure in the emergency department. J Trauma. 2006;61(5):1228-1233.
- Oyetunji TA, Chang DC, Crompton JG, et al. Redefining hypotension in the elderly: normotension is not reassuring. Arch Surg. 2011;146(7):865-869.
- Schreiber MA, Meier EN, Tisherman SA, et al. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial. J Trauma Acute Care Surg. 2015;78(4):687-695.
- Danks RR. Triangle of death. How hypothermia acidosis & coagulopathy can adversely impact trauma patients. JEMS. 2002;27(5):61-6, 68-70.
- Englehart MS, Schreiber MA. Measurement of acid-base resuscitation endpoints: lactate, base deficit, bicarbonate or what? Curr Opin Crit Care. 2006;12(6):569-574.
- Vandromme MJ, Griffin RL, Kerby JD, et al. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma. 2011;70(2):384-388.
- Nunez TC, Voskresensky IV, Dossett LA, et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009;66(2):346-352.
- Schroll R, Swift D, Tatum D, et al. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury. 2018;49(1):15-19.
- Schellenberg M, Strumwasser A, Grabo D, et al. Delta shock index in the emergency department predicts mortality and need for blood transfusion in trauma patients. Am Surg. 2017;83(10):1059-1062.
- Rahbar E, Fox EE, Del junco DJ, et al. Early resuscitation intensity as a surrogate for bleeding severity and early mortality in the PROMMTT study. J Trauma Acute Care Surg. 2013;75(1 Suppl 1):S16-23.
- Meyer DE, Cotton BA, Fox EE, et al. A comparison of resuscitation intensity and critical administration threshold in predicting early mortality among bleeding patients: a multicenter validation in 680 major transfusion patients. J Trauma Acute Care Surg. 2018;85(4):691-696.