What are the treatment guidelines for acute traumatic injuries in a Mobile Army Surgical Hospital (MASH) setting?

Treatment Guidelines for Acute Traumatic Injuries in MASH Settings

Immediate Triage and Risk Stratification

All severely injured patients must be immediately stratified into stable, intermediate, or unstable clinical status based on hemodynamic parameters, coagulation status, temperature, respiratory function, and associated injuries to guide surgical timing and approach. 1

The 2021 Anaesthesia guidelines provide a comprehensive grading system that should drive all subsequent decisions:

• Stable patients (no vasopressors, <2.5 mmol/L lactate, minimal coagulopathy, ISS <25) proceed to early safe definitive surgery 1
• Intermediate-risk patients (vasopressors 2-4 mg/h norepinephrine, lactate 2.5-4 mmol/L, moderate coagulopathy, ISS >25) require initial resuscitation and PRompt Individualised Safe Management (PRISM) 1
• Unstable patients (vasopressors >4 mg/h, lactate >4 mmol/L, severe coagulopathy, ISS >40) mandate damage control orthopaedics with mid-term stabilization followed by delayed definitive surgery 1

Hemorrhage Control: The Primary Determinant of Survival

Minimize time between injury and surgical bleeding control—every minute counts in preventing mortality from hemorrhagic shock. 1

For Patients with Identified Bleeding Source

• Proceed immediately to surgical bleeding control if hemorrhagic shock persists despite initial resuscitation 1
• Target systolic blood pressure of 80-100 mmHg until major bleeding is controlled—avoid aggressive fluid resuscitation to normal pressures as this disrupts clot formation 1
• Monitor serum lactate and base deficit every 30-60 minutes rather than relying on single hematocrit measurements, which are unreliable in acute hemorrhage 1

For Patients with Unidentified Bleeding Source

• Perform immediate FAST (focused abdominal sonography in trauma), CT scan, and measure lactate/base deficit 1
• Do not delay surgical intervention for extensive diagnostic workup in unstable patients 1

Damage Control Surgery: The Cornerstone of Severe Trauma Management

A damage control surgical approach is essential in severely injured patients and should be proactively planned as a one-hour time-limited procedure rather than attempting prolonged anatomical restoration. 1, 2, 3

Three-Phase Damage Control Approach

Phase I (Operating Room):

• Limit laparotomy to 60 minutes maximum in hypothermic, coagulopathic, acidotic patients 2
• Control hemorrhage through packing and temporary measures rather than definitive repair 1
• For pelvic ring disruptions: close and stabilize, followed by angiographic embolization or surgical packing 1
• Use external fixation for wide open fractures and unstable long bone injuries 1

Phase II (ICU):

• Physiological stabilization focusing on correcting hypothermia, acidosis, and coagulopathy 2, 3
• Actively warm patient and all transfused fluids 2, 3
• Duration varies from 2 hours to 2 days depending on physiological recovery 1

Phase III (Return to OR):

• Definitive repair once physiological parameters normalize 2
• 74% of damage control patients receive definitive surgery in the second procedure 4

Critical Physiological Thresholds

The operating theater is a hostile environment for severely injured patients—surgery must be viewed as part of resuscitation, not an end in itself 3. Damage control is indicated when patients exhibit:

• Deep hemorrhagic shock with ongoing bleeding 1
• Coagulopathy (PTr >1.5, fibrinogen <1 g/L, platelets <50,000/mm³) 1
• Hypothermia (<35°C, especially <34°C with vascular injury which quadruples mortality) 1, 2
• Severe acidosis (base deficit >6 mmol/L) 1

Limb-Threatening Injuries: Salvage vs. Amputation

In hemodynamically stable patients with mangled extremities, limb salvage should be attempted as psychological outcomes and quality of life remain superior when reimplantation succeeds. 1

However, in hemorrhagic shock with severe limb trauma complicated by vascular injury:

• Apply damage control strategy with temporary stabilization by external fixators 1
• No single gravity criterion mandates amputation—decision should be based on patient preferences and surgeon expertise 1
• Delayed amputation (if necessary) produces equivalent functional outcomes to immediate amputation 1
• Amputation distal to the knee provides better functional outcomes 1

Coagulation Management

Coagulation monitoring and support should be implemented as early as possible following traumatic injury and used to guide haemostatic therapy. 1

• Monitor PT, aPTT, fibrinogen, and platelet count serially 1
• Administer fresh frozen plasma, prothrombin complex concentrate, and coagulation factors based on laboratory values 1
• Consider tranexamic acid early in hemorrhaging patients 1
• Cease pro-coagulant measures once hemostasis is achieved to avoid thromboembolic complications 1

Blood Product Administration

• Transfuse packed red blood cells to maintain hemoglobin >7 g/dL in most patients 1
• Higher threshold (9 g/dL) for massive bleeding or significant cardiovascular comorbidities 1
• Warm all blood products before administration 2
• Expect to use approximately 14 units of blood and 7 units of FFP per damage control patient 2

Special Considerations for MASH Environment

Resource Intensity

Damage control surgery is extremely resource-intensive 2:

• Two DCS patients will exhaust a light-scaled field surgical team's oxygen supply in one day 2
• Plan for adequate blood product stockpiles (two DCS patients consume half the blood stock) 2
• Maintain operating room temperature >20°C to prevent hypothermia 2

Evacuation Timing

• Primary casualty retrieval should occur within 25 minutes of injury when possible 2
• Delays beyond 110 minutes significantly worsen outcomes 2
• Stabilize physiology before evacuation—do not evacuate unstable patients 2

Surgical Team Coordination

• Use two surgical teams operating simultaneously or overlapping to reduce operating time 5
• Ensure all team members understand damage control principles before procedures begin 3

Common Pitfalls to Avoid

• Never delay definitive bleeding control for extensive diagnostic workup in unstable patients 1
• Do not rely on blood pressure alone—some patients compensate well despite significant hemorrhage 1
• Avoid prolonged attempts at anatomical restoration in unstable patients—outcomes are determined by physiological limits, not surgical perfection 3
• Do not perform early definitive osteosynthesis in borderline or unstable patients—this significantly increases respiratory complications and mortality 1, 4
• Never attribute hemorrhagic shock to head injury alone—25% of abdominal hemorrhages are missed this way 5