Article by Christopher Hicks, MD, MEd, FRCPC and Andrew Petrosoniak, MD, MSc (MedEd), FRCPC, Guest Editors of the February 2018 issue of Emergency Medicine Clinics.

The approach to resuscitating a trauma patient in shock is due for a major re-think.  For decades, providers have subscribed to the erroneous notion that large amounts of crystalloid are required to replace intravascular volume for the trauma patient in shock.  Not only is this not accurate, but it is also, in many cases, counterproductive, worsening both early and late trauma coagulopathy. The February 2018 issue of Emergency Medicine Clinics highlights the practical ways in which trauma care has evolved, and how the role of emergency care providers must evolve with it.

In their article, “The Evolving Science of Trauma Resuscitation,” Harris et al provide a more rational framework for managing massive hemorrhage, shifting the focus from “normalizing” problematic vital signs to adequate tissue perfusion and hemostasis.  This approach is predicated on a series of premises described in the paper:

1. What constitutes a “normal” blood pressure in the context of massive hemorrhage involves imprecise estimates and tends to increase volume resuscitation with crystalloids.
2. Adequate tissue perfusion, defined as the presence of peripheral pulses and normal mentation, represents a more measurable endpoint: Volume resuscitation can be titrated to both, using smaller boluses of crystalloid or blood.

The order of operations in a patient with multiple critical injuries also merits re-examination. Advance Trauma Life Support (ATLS) endorses an ABCDE primary survey: a step-wise assessment of injuries that has been conflated with the imperative to manage injuries in the order they are identified.  In their article,“Resuscitation Resequenced: A rational approach to trauma patients in shock,” Petrosoniak and Hicks argue that rigid adherence to the “A before B before C” can lead to disastrous consequences. Instead, providers should re-order the approach to focus on physiologic priorities. In the absence of a dynamic airway (obstruction or imminent anatomic deterioration) or critical hypoxia (not corrected by simple temporizing interventions), immediate priorities are to identify and manage correctable causes of hemorrhagic and obstructive shock.

In a severely injured patient in shock, the following should precede definitive airway management:

1. Finger thoracostomy to decompress possible tension pneumothorax
2. Bedside cardiac echocardiography to identify pericardial effusion and tamponade
3. Pelvic binder application in the presence of a mechanically unstable pelvic fracture
4. Control of external bleeding with direct pressure or tourniquet application
5. Initiation of volume resuscitation by way of massive transfusion, prioritizing packed red blood cells or whole blood over crystalloid

This “re-think” is particularly pertinent to emergency physicians who manage major trauma, as they are most applicable in the very early stages of resuscitation, prior to diagnostic imaging and operative control of bleeding.  Indeed, the decisions made by emergency physicians in the first 15-20 minutes may ultimately determine whether a patient arrives to their next step in care warm and well-perfused, or cold, acidotic, and coagulopathic.

Christopher Hicks and Andrew Petrosoniak are emergency physicians, trauma team leaders and clinician-educators at St. Michael’s Hospital in Toronto, Canada.  Their program of research focuses on improving individual, team, process and system performance in trauma resuscitation.  Follow them on Twitter: @HumanFact0rz and @Petrosoniak.