What are the latest guidelines for managing severe trauma?

Latest Guidelines in Severe Trauma Management

The management of severe trauma follows a systematic approach prioritizing hemorrhage control, airway management with normoventilation, and prevention of the lethal triad (hypothermia, acidosis, coagulopathy), with specific modifications for traumatic brain injury patients who require higher blood pressure targets.

Prehospital Phase: Immediate Life-Saving Interventions

Hemorrhage Control Takes Priority

• Apply tourniquets immediately for life-threatening extremity bleeding before addressing airway concerns, as this is the leading preventable cause of death 1
• Tourniquets should remain in place until surgical control is achieved, ideally less than 2 hours, though military data demonstrates extremity survival up to 6 hours 2
• For suspected pelvic fractures with shock, apply external pelvic binders positioned around the greater trochanters (not iliac crests) as soon as possible 2, 1

Fluid Resuscitation Strategy

• Target systolic blood pressure 80-90 mmHg (MAP 50-60 mmHg) using restricted fluid resuscitation until bleeding is controlled—this is permissive hypotension 1
• Critical exception: In traumatic brain injury (GCS ≤8), maintain MAP ≥80 mmHg to ensure adequate cerebral perfusion, as hypotension exacerbates secondary brain injury 1, 3
• Initiate crystalloids initially within the first 3 hours, but avoid hypotonic solutions like Ringer's lactate in severe head trauma 2
• Volumes exceeding 2000ml increase coagulopathy risk to over 40% 1

Hypothermia Prevention

• Remove wet clothing immediately, apply warming blankets, and shield patients from wind and ground contact 2, 1
• Hypothermia is present in up to two-thirds of severely injured patients and significantly increases mortality when temperature drops below 32°C 2

Transport Decisions

• Transport all severe trauma patients directly to designated Level 1 trauma centers, not the nearest hospital 1

Hospital Phase: Emergency Department Management

Airway and Ventilation

• Maintain normoventilation (PaCO2 35-40 mmHg) in all trauma patients unless signs of imminent cerebral herniation are present 2, 1, 3
• Hyperventilation increases mortality through cerebral vasoconstriction, decreased cerebral blood flow, and impaired venous return in hypovolemic patients 2, 1
• For emergency tracheal intubation, use rapid sequence intubation with direct laryngoscopy as the gold standard, with manual in-line stabilization for potential cervical spine injury 4, 5
• Succinylcholine remains the recommended neuromuscular blockade agent for rapid sequence intubation 4

Initial Assessment

• Clinically assess hemorrhage severity using mechanism of injury, patient physiology (vital signs), anatomical injury pattern, and response to initial resuscitation 2, 1
• The ATLS classification defines four classes of hemorrhage: Class I (<15% blood loss), Class II (15-30%), Class III (30-40%), and Class IV (>40%) 2
• Perform Focused Assessment with Sonography for Trauma (FAST) for rapid detection of free intraperitoneal fluid 6, 7
• Record core temperature immediately using esophageal, bladder, or rectal probes—peripheral measurements are unreliable 1

Imaging Strategy

• Contrast-enhanced CT is the gold standard for hemodynamically stable patients to identify specific organ injuries and detect active arterial extravasation 6, 7
• For hemodynamically unstable patients with positive FAST or peritonitis, proceed directly to operating room without CT 6, 7

Surgical Decision-Making

Indications for Immediate Surgery

• Damage control surgery should be employed in severely injured patients presenting with deep hemorrhagic shock, signs of ongoing bleeding, and coagulopathy 2
• Additional triggers include severe hypothermia, acidosis, inaccessible major anatomic injury, need for time-consuming procedures, or concomitant major injury outside the abdomen 2
• Immediate laparotomy is indicated for persistent hemodynamic instability, peritonitis, evisceration, uncontrolled gastrointestinal bleeding, or pneumoperitoneum 6

Damage Control Approach

• Damage control surgery consists of three phases: initial hemorrhage control, resuscitation in ICU, and definitive surgery once physiologic parameters normalize 6
• The goal is hemostasis and prevention of secondary damage (contamination, compartment syndrome), with temporary fracture stabilization using external fixation 7

Traumatic Brain Injury-Specific Management

Severity Classification and Monitoring

• Classify TBI severity using Glasgow Coma Scale: severe (GCS ≤8), moderate (GCS 9-13), mild (GCS 14-15) 3
• ICP monitoring is strongly indicated in severe TBI patients with abnormal CT findings, as over 50% will develop intracranial hypertension 3
• ICP of 20-40 mmHg increases mortality risk 3.95-fold; above 40 mmHg, risk increases 6.9-fold 3

Critical Parameters for TBI

• Maintain cerebral perfusion pressure (CPP) ≥60 mmHg when ICP monitoring is available 3
• Maintain PaO2 between 60-100 mmHg 3
• Maintain PaCO2 between 35-40 mmHg during routine management 3
• Maintain platelet count >50,000/mm³ for life-threatening hemorrhage and higher for neurosurgical interventions 3

Management of Intracranial Hypertension

• Suspect intracranial hypertension when major criteria present (compressed cisterns, midline shift >5mm, non-evacuated mass lesion) or two minor criteria (GCS motor score ≤4, pupillary asymmetry, abnormal reactivity, Marshall diffuse injury II) 3
• Use osmotherapy with hypertonic saline or mannitol for refractory intracranial hypertension 3
• Avoid hypo-osmolar fluids that worsen cerebral edema 3
• Decompressive craniectomy may reduce mortality (26.9% vs 48.9%) but potentially increases severe disability 3

Polytrauma with TBI: The Critical Balance

• For patients with both TBI and hemorrhagic shock, never use permissive hypotension strategies—these patients require MAP ≥80 mmHg despite ongoing bleeding 3
• This creates a challenging balance between addressing life-threatening hemorrhage and preventing secondary brain injury 3
• Arterial hypotension exacerbates cerebral secondary damage and must be avoided 3

Common Pitfalls to Avoid

• Never hyperventilate trauma patients routinely—this practice increases mortality 2, 1
• Never give large-volume crystalloid resuscitation (>2000ml) in the prehospital setting—this worsens coagulopathy 1
• Never apply permissive hypotension in TBI patients—they require higher MAP targets 1, 3
• Never overlook temperature documentation—one major trauma center documented temperature in only 38% of admissions 1
• Never place pelvic binders incorrectly—they must be positioned around the greater trochanters to be effective 1
• Never use Ringer's lactate in severe head trauma—hypotonic solutions worsen cerebral edema 2

Recent Advances

• Tranexamic acid administration in the prehospital setting has shown promise for reducing mortality when given within 3 hours of injury 8, 9
• Intraosseous vascular access has improved outcomes when traditional IV access is difficult 8
• Point-of-care coagulation tests (TEG, ROTEM) should be utilized when available to guide coagulation management 3
• The "CAB" (Circulation, Airway, Breathing) assessment emphasizes managing life-threatening hemorrhages before airway in some protocols 8