What are the guidelines for resuscitating trauma patients?

From the Guidelines

Trauma resuscitation should follow a systematic approach prioritizing airway, breathing, and circulation management, with the most recent and highest quality evidence guiding the use of permissive hypotension, balanced transfusion strategies, and tranexamic acid administration, as recommended by the European guideline updated in 2013 1.

Key Components of Trauma Resuscitation

• Securing the airway through endotracheal intubation if the patient has a Glasgow Coma Scale score below 8 or cannot maintain airway patency
• Providing supplemental oxygen to maintain saturation above 94% and considering needle or tube thoracostomy for tension pneumothorax
• Controlling hemorrhage immediately using direct pressure, tourniquets for extremity bleeding, or hemostatic agents
• Establishing two large-bore IV access (16-18 gauge) and initiating fluid resuscitation with 1-2 liters of warm crystalloids (normal saline or lactated Ringer's solution), followed by blood products for ongoing hemorrhage
• Using a balanced transfusion strategy with 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets for massive transfusion, as supported by the updated guideline 1
• Maintaining systolic blood pressure around 90 mmHg (permissive hypotension) in hemorrhagic shock until bleeding is controlled, except in traumatic brain injury where MAP should be kept above 80 mmHg, as recommended by the guideline 1
• Administering tranexamic acid 1g IV over 10 minutes followed by 1g over 8 hours if given within 3 hours of injury, as supported by the evidence 1

Ongoing Monitoring and Care

• Continuously monitoring vital signs, urine output (target >0.5 mL/kg/hr), core temperature (prevent hypothermia below 36°C), and point-of-care testing for metabolic derangements
• Preventing the lethal triad of hypothermia, acidosis, and coagulopathy that worsens trauma outcomes, as emphasized by the guideline 1

Evidence-Based Recommendations

The European guideline updated in 2013 1 provides a comprehensive approach to trauma resuscitation, emphasizing the importance of permissive hypotension, balanced transfusion strategies, and tranexamic acid administration. The guideline is based on a systematic review of published literature and was formulated using a nominal group process and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. The recommendations are supported by the highest quality evidence available, making them a reliable guide for trauma resuscitation.

From the Research

Resuscitation Guidelines for Trauma Patients

• The guidelines for resuscitating trauma patients emphasize the importance of judicious use of crystalloids, as over-aggressive intravenous fluid therapy with crystalloids has been associated with adverse effects, including increased mortality and longer time ventilated 2.
• A study on pediatric wartime trauma casualties found that high crystalloid volumes negated the benefit of hemostatic resuscitation, which includes limiting crystalloids and using closer to 1:1 ratios for both fresh frozen plasma and platelets relative to packed red blood cells 3.
• The choice of fluid for resuscitation is also important, as a study found that lactated Ringer's solution was associated with higher adjusted mortality compared to normal saline in patients with traumatic brain injury 4.
• The crystalloid to packed red blood cell transfusion ratio is also a critical factor, as a higher ratio has been associated with increased morbidity and poor outcome after massive transfusion 5.
• Alternative blood products, such as tranexamic acid and prothrombin complex concentrate, may be considered in trauma patients, especially when blood products are scarce 6.

Key Considerations

• Limit crystalloid administration to avoid adverse effects
• Use closer to 1:1 ratios for fresh frozen plasma and platelets relative to packed red blood cells
• Choose the appropriate fluid for resuscitation based on patient condition
• Monitor the crystalloid to packed red blood cell transfusion ratio to minimize morbidity and poor outcome
• Consider alternative blood products when necessary

Fluid Administration

• Crystalloids should be used judiciously, with careful consideration of the potential risks and benefits 2, 3
• The type of crystalloid used may also impact patient outcomes, with lactated Ringer's solution associated with higher mortality in traumatic brain injury patients 4
• The crystalloid to packed red blood cell transfusion ratio should be monitored and minimized to reduce morbidity and poor outcome 5