In all of the CICM past exams, the topic of haemostatic resuscitation has only come up twice, as part (b) of Question 20 from the first paper of 2011 and Question 23 from the first paper of 2022. In addition to this, one other SAQ (Question 10 from the first paper of 2020) had asked about the strategies one could use to decrease the PRBC transfusion requirements in an acutely bleeding trauma patient, which is essentially a question about haemostatic resuscitation.
There is a lot written on this topic- much more than an exhausted exam candidate can be expected to internalise. As always, LITFL says it best. For a good long-form review, one may turn either to Heiko Lier et al (2008) or to this 2016 dissertation by Lana Castellucci. The Critical Bleeding/Massive Tranfusion Module from the National Blood Authority is the definitive resource for the "official position". The main message is the management of the "lethal triad" - correction of hypothermia, acidosis and coagulopathy. At the same time, it is important to limit the total amount of infused crystalloid, so as to avoid excessive organ oedema.
Traditional methods of trauma resuscitation were "unbalanced". Historically, vast volumes of crystalloid would be funnelled into the patient in order to restore the circulating volume, with occasional units of packed cells thrown in randomly whenever the haemoglobin result comes back low. Then, when coags become abnormal, other blood products would be used. The goal was to flog the patient with fluid boluses, with the goal being a normal arterial blood pressure. This carried on for some time, even though from the literature of the period (eg. Shoemaker at al, 1976) it seems the disadvantages of this approach were already clear.
Such unbalanced resuscitation strategies lead to depletion of coagulation factors and exacerbation of dilutional coagulopathy. The oedematous tissues would swell, limiting vascular access and creating compartment syndromes. Oedematous organs would refuse to work. Lungs would fill with oedema and become stiff; oedematous gut would refuse to perform normal peristaltic work, and oedematous anastomotic sites would break down due to poor perfusion. If non-blood colloids were used, they would either clog the kidneys (hydroxyethyl starch) or incorporate themselves into newly formed clots, degrading the clot integrity (gelofusine).
In short, the old way didn't work very well. The new paradigm of trauma resuscitation is to preserve coagulation at all costs, while keeping the cardiac output at whatever minimum is required to maintain vital organ perfusion. A summarised series of arguments for this new paradigm are offered below:
Many studies are available; this is merely a selection of famous representatives.
The following suggestions are concocted from lots of sources, none of which are directly credited, but which include LITFL, UpToDate and the abovelisted trial/cohort evidence.
Within the first 6 hours:
These are being offered as a reasonable-sounding list of goals, on the basis of the evidence above, as well as using the college answer to Question 7 from the second paper of 2015. These goals should be achieved at the end of the first six hours of resuscitation
Question 10 from the first paper of 2020 asked the exam candidates about how they would "reduce the red cell transfusion requirements in an actively bleeding multiple trauma patient". Without having thought about this previously, this answer would have been quite difficult to approach. One could conceivably separate it into two main components: stop the bleeding, and stop transfusing. An excellent article by Tinmouth et al (2008) supports this section, even though it was written about ICU patients in general, rather than trauma patients.
Prevent further haemoglobin loss:
Prevent wasteful use of blood products:
Shoemaker, William C. "Comparison of the relative effectiveness of whole blood transfusions and various types of fluid therapy in resuscitation." Critical care medicine 4.2 (1976): 71-78.
El Sayad, Mohamed, and Hussein Noureddine. "Recent Advances of Hemorrhage Management in Severe Trauma." Emergency medicine international 2014 (2014).
Castellucci, Lana Antoinette. Evaluating Risk of Delayed Major Bleeding in Critically Ill Trauma Patients. Diss. University of Ottawa, 2016.
Stensballe, Jakob, and John B. Holcomb. "Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage—But did they in fact test the effect of hemostatic resuscitation?." Journal of Trauma and Acute Care Surgery 78.6 (2015): 1237.
MacLeod, Jana BA, et al. "Early coagulopathy predicts mortality in trauma." Journal of Trauma and Acute Care Surgery 55.1 (2003): 39-44.
Lier, Heiko, et al. "Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma." Journal of Trauma and Acute Care Surgery 65.4 (2008): 951-960.
Sankarankutty, Ajith, et al. "TEG® and ROTEM® in trauma: similar test but different results." World J Emerg Surg 7.Suppl 1 (2012): S3.
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Duchesne, Juan C., et al. "Damage control resuscitation in combination with damage control laparotomy: a survival advantage." Journal of Trauma and Acute Care Surgery 69.1 (2010): 46-52.
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CRASH-2 collaborators. Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y et al. "Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial." Lancet 376 (2010): 23-32.
Volpi, Annalisa, Silvia Grossi, and Roberta Mazzani. "Tranexamic Acid in Trauma Patients." Reducing Mortality in Critically Ill Patients. Springer International Publishing, 2015. 39-45.
Roberts, I., et al. "The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients." Health Technology Assessment 17.10 (2013).
Morrison, Jonathan J., et al. "Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study." Archives of surgery 147.2 (2012): 113-119.
Holcomb, John B., et al. "The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks." JAMA surgery 148.2 (2013): 127-136.
Holcomb, John B., et al. "Transfusion of plasma, platelets, and red blood cells in a 1: 1: 1 vs a 1: 1: 2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial." JAMA 313.5 (2015): 471-482.
Curry, N., et al. "Early cryoprecipitate for major haemorrhage in trauma: a randomised controlled feasibility trial." British journal of anaesthesia (2015): aev134.
Khan, Sirat, et al. "Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage." Journal of Trauma and Acute Care Surgery 76.3 (2014): 561-568.
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Tinmouth, Alan T., Lauralynn A. McIntyre, and Robert A. Fowler. "Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients." Cmaj 178.1 (2008): 49-57.
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