What is the initial management of trauma patients with severe bleeding?

Initial Management of Trauma Patients with Severe Bleeding

The initial management of trauma patients with severe bleeding should focus on minimizing time to bleeding control, with immediate surgical intervention for those with identified bleeding sources and hemodynamic instability. 1

Initial Assessment and Stabilization

• Assess the extent of traumatic hemorrhage using an established grading system such as the Advanced Trauma Life Support (ATLS) classification, which evaluates blood loss based on vital signs, mental status, and clinical presentation 1, 2
• Avoid hyperventilation and excessive positive end-expiratory pressure (PEEP) in severely hypovolemic trauma patients as this can decrease cardiac output and worsen outcomes 1, 2
• Secure large-bore intravenous access for rapid fluid resuscitation 2
• Apply external pelvic compression as soon as possible in all patients with suspected severe pelvic trauma, preferably using pelvic binders placed around the great trochanters 1
• Control obvious bleeding points using direct pressure, tourniquets, or hemostatic dressings 2, 3
• Actively warm the patient and all transfused fluids to prevent hypothermia, which worsens coagulopathy 2

Diagnostic Evaluation

• For patients with suspected torso trauma, perform early focused sonography (FAST) for detection of free fluid 1
• Patients with hemodynamic instability and significant free intraabdominal fluid should undergo urgent surgery 1
• For hemodynamically stable patients with suspected head, chest, or abdominal bleeding following high-energy injuries, perform CT scan with intravenous contrast 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding 1
• Measure serum lactate and base deficit to estimate and monitor the extent of bleeding and shock 1

Resuscitation Strategy

• Target a systolic blood pressure of 80-100 mmHg until major bleeding has been stopped in patients without brain injury (permissive hypotension) 1
• Initially use crystalloids for fluid resuscitation, with colloids added within prescribed limits for each solution 1
• For massive hemorrhage, administer warmed blood and blood components 2
• Consider antifibrinolytic agents such as tranexamic acid at a dose of 10-15 mg/kg followed by an infusion of 1-5 mg/kg/h 1, 4
• Administer tranexamic acid within one hour of injury for maximum benefit in reducing mortality 5

Source Control

• Minimize time between injury and operation for patients requiring urgent bleeding control 1
• Patients with hemorrhagic shock and an identified source of bleeding should undergo immediate bleeding control procedure unless initial resuscitation measures are successful 1
• For patients with hemorrhagic shock and an unidentified source of bleeding, perform immediate further assessment 1
• For patients with pelvic ring disruption in hemorrhagic shock, perform immediate pelvic ring closure and stabilization 1
• Patients with ongoing hemodynamic instability despite adequate pelvic ring stabilization should receive early angiographic embolization or surgical bleeding control, including packing 1

Damage Control Approach

• Employ a damage control surgical approach in severely injured patients presenting with deep hemorrhagic shock, signs of ongoing bleeding, coagulopathy, hypothermia, or acidosis 1, 6
• Early bleeding control should be achieved using packing, direct surgical bleeding control, and local hemostatic procedures 1
• The damage control resuscitation concept prioritizes recovery of physiological variables over anatomical variables in severe trauma patients 6

Common Pitfalls and Considerations

• Avoid delays between injury and surgical intervention for patients requiring urgent bleeding control 1
• Do not rely solely on blood pressure as an indicator of blood loss, as some patients compensate well despite significant hemorrhage 2
• Be cautious with tranexamic acid administration timing—benefits decrease when given after 3 hours from injury, and may potentially increase risk of death due to bleeding when given after this time window 5
• Rapid intravenous injection of tranexamic acid can cause hypotension and carries a risk of thrombosis and seizures 4, 5
• Avoid vasopressors once control of bleeding is achieved as they may mask ongoing hemorrhage 2