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.

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:

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

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.

Oral resuscitation

Per-oral resuscitation is safe and efficient in patients without abdominal injury who have a positive gag reflex:

Analgesia

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.



Urine

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.

Blood transfusion

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 patient’s own family.

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.