The goal is to stop bleeding and restore oxygen
delivery to the tissues. As the usual problem is loss of blood,
fluid resuscitation must be a priority.
||Obtain adequate vascular access
This requires the insertion of at least two large-bore cannulas (14–16
G), if available. Peripheral cut down may be necessary.
Infusion fluids (crystalloids, such as normal saline, as the first line) should
be warmed to body temperature, if possible (prewarm in a bucket of warmed water).
||Hypothermia can lead to abnormal blood clotting
||Avoid solutions containing glucose.
Take any specimens you need for laboratory tests and crossmatching.
FIRST PRIORITY: STOP THE BLEEDING
Injuries to the limbs
Tourniquets do not work and, besides, cause reperfusion syndromes and add to
the primary injury.
The recommended procedure of “pressure dressing” is an ill-defined
entity. Severe bleeding from high-energy penetrating injuries and amputation
wounds can be controlled by:
||Subfascial gauze pack placement
||Manual compression on the proximal artery
||Carefully applied compressive dressing of the entire
Injuries to the chest
The most common source of bleeding is chest wall arteries. Immediate infield
placement of a chest tube drain plus efficient analgesia (IV ketamine is the
drug of choice) expands the lung and seals off the bleeding.
Injuries to the abdomen
“Damage control (DC) laparotomy” should be performed
as soon as possible on cases where fluid resuscitation cannot
maintain a systolic BP at 80–90 mmHg. The sole objective
of DC laparotomy is to gauze pack the bleeding abdominal quadrants,
after which the midline incision is temporarily closed within
30 minutes with towel clamps.
DC laparotomy is not surgery, but a resuscitative procedure
that any trained doctor or nurse at district level should be
able to do under ketamine anaesthesia. The technique needs
to be observed before performing it but, done correctly, it
can save lives.
Loss of blood is the main cause of shock in trauma patients.
Bleeding from massive pelvic fractures
Bleeding from massive pelvic fractures may be controlled by
tying a sheet around the pelvis.
SECOND PRIORITY: VOLUME REPLACEMENT,
WARMING AND KETAMINE ANALGESIA
Replacement fluids should be warm. Physiological coagulation
works best at 38.5 °C and haemostasis is difficult at core
temperatures below 35 °C. Hypothermia in trauma patients
is common during protracted improvised outdoor evacuations – even
in the tropics. It is easy to cool a patient but difficult
to re-warm, hence prevention of hypothermia is essential.
Oral and IV fluids should have a temperature of 40°C – 42°C;
using IV fluids at “room temperature” means cooling!
Hypotensive fluid resuscitation
In cases where the haemostasis is insecure or not definitive,
control the fluid volume to maintain systolic BP at 80–90
mmHg during the transfer of a critically-ill, bleeding patient.
Per-oral resuscitation is safe and efficient in patients without
abdominal injury who have a positive gag reflex:
||Oral fluids should be low in sugar and salts;
concentrated solutions can cause an osmotic pull over the
intestinal mucosa and the effect will be negative
||Diluted cereal porridges, based on local foodstuffs,
Ketamine is the analgesic choice in repeated IV doses of 0.2
mg/kg during evacuation of all severe trauma cases because
of the positive inotropic effects and the fact that it does
not affect the gag reflex.
Measure urine output as an indicator of circulation reserve.
Output should be more than 0.5 ml/kg/hour. Unconscious patients
may need a urinary catheter if they are persistently shocked.
There may be considerable difficulty in getting blood. Remember
possible incompatibility and the risks of transfusion-transmissible
infection (including HIV, malaria, syphilis), even among the
Blood transfusion must be considered when the patient has persistent
haemodynamic instability despite fluid (colloid/crystalloid)
infusion. If typespecific or crossmatched blood is not available,
use group O negative packed red blood cells. Transfusion should,
however, be seriously considered if the haemoglobin level is
less than 7 g/dl and the patient is still bleeding.