In the immediate post resuscitation phase, pending transfer to the operating theatre / an appropriate high care area / hospital, the patient should be treated following the principles of the ABCDE approach.
Place an advanced airway if not already insitu.
Maintain SpO2 94 – 98%.
Ensure waveform capnography and ventilate lungs to maintain normocapnia.
If bleeding, then pending transfer to OT maintain a palpable BP if no TBI or aim for maintaining BP>110 if TBI.
Obtain reliable IV access.
Blood / fluid replacement – restore normovolaemia and coagulation.
Obtain 12 lead ECG.
Continuous cardiac monitoring.
Check pupillary response.
Exposure and environment:
Monitor temperature and keep >35C for bleeding patient.
Look for any previously unidentified sites of possible haemorrhage.
The principles of damage control resuscitation (DCR) have been adopted into trauma resuscitation for uncontrolled haemorrhage. DCR aims to maintain circulating volume, control haemorrhage and correct the ‘lethal triad’ of coagulopathy, acidosis and hypothermia until definitive intervention is appropriate. It is based on military trauma experience and uses a systematic approach with the following underlying management principles:
A conservative approach to IV fluid administration which involves infusion of a sufficient volume in order to maintain a radial pulse in the patient with ROSC. This is usually targeted at a SBP of 80-90mmHg, enough to maintain cerebral perfusion. In the patient with a suspected head injury, this should be targeted at >110.
Early haemostatic resuscitation
Early administration of blood products helps to prevent complications of aggressive crystalloid fluid resuscitation leading to the acute coagulopathy of trauma.
Damage control surgery
Refers to urgent limited surgical interventions in order to control haemorrhage until the patient is able to undergo definitive interventions.