Elsevier

The Lancet

Volume 380, Issue 9847, 22–28 September 2012, Pages 1099-1108
The Lancet

Series
Haemorrhage control in severely injured patients

https://doi.org/10.1016/S0140-6736(12)61224-0Get rights and content

Summary

Most surgeons have adopted damage control surgery for severely injured patients, in which the initial operation is abbreviated after control of bleeding and contamination to allow ongoing resuscitation in the intensive-care unit. Developments in early resuscitation that emphasise rapid control of bleeding, restrictive volume replacement, and prevention or early management of coagulopathy are making definitive surgery during the first operation possible for many patients. Improved topical haemostatic agents and interventional radiology are becoming increasingly useful adjuncts to surgical control of bleeding. Better understanding of trauma-induced coagulopathy is paving the way for the replacement of blind, unguided protocols for blood component therapy with systemic treatments targeting specific deficiencies in coagulation. Similarly, treatments targeting dysregulated inflammatory responses to severe injury are under investigation. As point-of-care diagnostics become more suited to emergency environments, timely targeted intervention for haemorrhage control will result in better patient outcomes and reduced demand for blood products. Our Series paper describes how our understanding of the roles of the microcirculation, inflammation, and coagulation has shaped new and emerging treatment strategies.

Introduction

Exsanguinating haemorrhage is the most common preventable cause of death after trauma.1 It causes approximately a third of the almost six million trauma deaths per year. About half occur before the patient reaches the hospital. All civilian and military trauma systems face the challenge of ensuring that bleeding patients receive timely and effective haemorrhage control.

Key messages

  • •

    Contemporary approaches to haemorrhage control combine early control of bleeding, management of coagulopathy, maintenance of critical perfusion, and management of the inflammatory response

  • •

    Early haemorrhage control minimises genomic activation and the harmful inflammation and coagulopathy caused by shock and resuscitation

  • •

    Topical haemostatic agents and interventional radiology are useful adjuncts to surgical control of bleeding

  • •

    Several pathogenic mechanisms contribute to trauma-induced coagulopathy, and the predominant mechanism changes during the clinical course

  • •

    Blind unguided protocols for blood component therapy in haemorrhagic shock and coagulopathy have safety and logistic concerns and trials of their effectiveness are underway

  • •

    Systemic treatments for coagulopathy might reduce the reliance on and demand for blood products

  • •

    Broad-acting drugs, such as tranexamic acid, that potentially affect inflammation, coagulation, and fibrinolysis, could modify responses to shock and improve outcomes

  • •

    In the future, treatments for haemorrhagic shock will be tailored to an individual's response by use of point-of-care tests and targeted therapies

Treatment approaches to haemorrhagic shock have transformed during the past two decades. From the Vietnam War until the 1990s, patients in shock received aggressive volume resuscitation with crystalloid solutions. More recent practices emphasise early administration of blood component therapies and tolerance of moderate hypotension until bleeding is controlled. These developments, which were consolidated in the Iraq and Afghanistan wars, are affecting the role of surgery in trauma patients. Previously, inability to prevent physiological exhaustion in exsanguinating patients meant that the primary focus in the operating theatre was damage control—ie, abbreviated initial surgery followed by ongoing resuscitation in the intensive-care unit. However, improvements in early bleeding cessation and haemostatic component resuscitation resulting in less physiological disturbance mean that completion of definitive treatment is often possible in the first operation.2

Much of our understanding of haemorrhage control is based on observational studies and preclinical research, which have characterised the physiological derangements of the shock state and the effects of treatment. This piecemeal collection of evidence supports contemporary approaches that aim to minimise dysregulated immune responses and harmful systemic effects of resuscitation.

Our Series paper describes how our knowledge of the microcirculation, inflammation, and coagulation has shaped new and emerging treatment strategies (table 1).

Section snippets

Microcirculation in haemorrhagic shock

Intravital microscopy has enabled better understanding of the crucial role that the microcirculation plays in mediation of the response to haemorrhagic shock and the inadequacy of fluid resuscitation as the only treatment.3 Haemorrhage and resuscitation induce cellular changes that are characteristic of ischaemia–reperfusion injury—eg, production of reactive oxygen species, activation of inflammation, and apoptotic cell death (figure 1).4

The immunoinflammatory response comprises both innate and

Early control of bleeding

In actively bleeding patients, prompt arrest of pronounced haemorrhage is the most important intervention to prevent death and reduce the harmful consequences of inflammation and resuscitation. Immediate compression of external wounds by a first responder or paramedic can substantially reduce volume loss. Limb tourniquets can control haemorrhage without high rates of adverse limb outcomes in patients with combat-related injuries,9, 10 and new devices have been designed that can effectively

Trauma-induced coagulopathy

Coagulopathy usually accompanies severe haemorrhage in trauma patients. As many as 25% of severely injured trauma patients have an established coagulopathy when they arrive in the emergency department.22 The incidence and severity of coagulopathy increase in hospital as bleeding continues and additional injuries are induced by infusions, transfusions, and surgical dissections. Coagulopathy is associated with early and late mortality23, 24 and increased incidence of subsequent acute lung injury,

Maintenance of critical perfusion

The third goal of haemorrhage control is to maintain adequate perfusion before, during, and after arrest of bleeding and thereby minimise further cellular and organ injury. Perfusion and inflammation are closely related; inflammation is a consequence of hypoxic tissue damage during low-flow states, over-resuscitation, and the generation of reactive oxygen species during reperfusion.

Restrictive fluid resuscitation is standard care in many trauma systems. Early aggressive resuscitation of

Management of the inflammatory response

Specific treatments to attenuate the inflammatory response to haemorrhagic shock are under investigation. They show the prevailing reductionist approach to the molecular basis of disease, and research has mainly focused on isolated components of the complex immunological processes. A wide range of mediators, including cytokines, cell-membrane lipids, enzymes, and oxidants, have all been implicated and, in most cases, have been investigated in well controlled murine models designed to mimic

Early and personalised interventions

Despite improved knowledge about the microcirculation, inflammation, and coagulation, treatment options are few and therapeutic targets are still poorly understood. In particular, treatment protocols do not factor in the coagulation state of patients or their likely response to transfusion. Diagnostic tests such as prothrombin and partial thromboplastin times are inaccurate, do not indicate coagulation functional status in trauma, and are not back in time to guide treatment during active

Search strategy and selection criteria

We searched Medline, Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, and Embase with the core terms “hemorrhagic shock”, “wounds and injuries”, “blast injuries”, “fluid resuscitation”, and “trauma” and the keywords “damage control”, “fluid therapy”, “hemostatic agents”, “permissive hypotension”, “blood component”, “transfusion”, and “angioembolisation”. The appendix includes a full list of search terms. We restricted our searches of these databases to studies

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