The first and last 15 minutes of trauma management are critical in giving your patient the best chance of functional survival. In this podcast we gain perspectives from both academic trauma team leaders Dr. Chris Hicks and Dr. Andrew Petrosoniak and community trauma expert Dr. Kylie Bosman in these critical moments. In this part 1 we answer questions on trauma resuscitation such as: how should we best prepare our team, our gear and ourselves for the trauma patient? How does resequencing the initial trauma resuscitation save lives? How can we most readily identify occult shock, the silent killer in trauma? What are 7 actions to consider in the first 15 minutes of resuscitation? How can the concepts of “controlled resuscitation” and “resuscitation intensity” help us decide resuscitation targets and when to activate a massive transfusion protocol? and many more…

Podcast production, sound design & editing by Anton Helman. Voice editing by Sucheta Sinha.

Written Summary and blog post by Shaun Mehta & Anton Helman, December, 2018

Cite this podcast as: Helman, A, Bosman, K, Hicks, C, Petrosoniak, A. Trauma – The First  and Last 15 Minutes Part 1. Emergency Medicine Cases. December, 2018. https://emergencymedicinecases.com/trauma-first-last-15-minutes-part-1/. Accessed [date].

Prepare the team, your gear and yourself for trauma resuscitation

Preparing the team for trauma

Prepare your team in the few minutes prior to the patient arriving in your ED based on the little information you have garnered from the EMS call, so that this complex logistical co-ordination can occur as an efficient flow [1].

Team-Based Preparation: 4 Discussion Points

  1. What do we know? The stem that you receive from the EMS call
  2. What do we expect to see/What are the possibilities? Run through the most likely immediate life-threatening issues/injuries
  3. What do we do? And discuss contingencies if those actions fail. What is your response if the initial plan fails or does not produce expected results?
  4. Role assignment. Assign logistical tasks to team members.

Team Preparation with Hicks from SMACC

Preparing the gear for trauma resuscitation

Ensure that your ED has a well thought out trauma cart that clearly contains the gear that you may require, including a pelvic binder, thoracostomy kit, cricothyrotomy kit etc. When assigning roles, assign gear preparation with each role.

Preparing yourself for trauma resuscitation

Mental preparation, including visualization of complex tasks, deep breathing exercises, and positive self-talk to help focus. See Weingart’s ‘Beat the Stress Fool‘ technique.

Consider calling for help early (anesthesia, surgery, orthopaedics, paediatrics etc) if you work in a center that does not have a dedicated trauma team. Tie up loose ends with other patients in your ED if time permits before the trauma patient arrives, so that after you’re done managing the trauma patient, your ED is not a disaster zone.

Resequencing the trauma resuscitation

Intubation causes an increase in intrathoracic pressure, resulting in a decrease in right atrial pressure which negatively impacts both hemorrhagic and obstructive shock. Pre-intubation hypotension is a significant risk factor for postintubation cardiac arrest. Hence, the adage “resuscitate before you intubate” in volume depleted patients, and procedures to relieve obstructive shock such as bilateral finger thoracostomies and thoracotomy, should be considered prior to endotracheal intubation.

Focus on physiologic priorities rather than always “ABC”. Tailor your approach to the most severe life-threatening injuries first. Vocalize your assessment and plan.

Two categories of immediate life-threats in trauma:

  1. Massive external hemorrhage
  2. Critical airway compromise a) critical/refractory hypoxia (<90% oxygen saturation despite maximal noninvasive ventilation) b) dynamic airway (anticipate evolving disruption of airway, head/neck injuries that are expected to worsen over the next few minutes)

Once these two immediate life threats have been ruled out or managed, resuscitation should focus on hemodynamic optimization before definitive airway management.

traumar esuscitation resquenced

Source – Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock. Emergency Medicine Clinics of North America [2].

Occult shock in trauma resuscitation

The early identification of occult shock is important because under-recognition is associated with worse patient outcomes.

How to assess for occult shock in the first 15 minutes of trauma resuscitation

  1. Calculate the Shock index (HR/SBP) [10] and/or delta Shock Index; if shock index > 1 or delta Shock Index ≥ 0.1, assume occult shock
  2. Assess the lowest BP measured and trend of BP over time; if isolated or persistent SBP <110, assume occult shock [7]
  3. FAST positive with flat IVC
  4. Feel for the presence of peripheral pulses and look for signs of poorly perfused extremities
  5. Altered LOA in the absence of severe head injury

Shock index >1 or Delta Shock Index ≥0.1 is a sign of occult shock and is predictive of post-intubation hypotension, transfusion requirements, injury severity and mortality

A single drop in BP in the field or in the ED is predictive of need for surgical intervention and mortality. An isolated decrease in SBP <105 mmHg is associated with a 12-fold increase in the need for immediate therapeutic intervention [6].

Pearl: When receiving handover from EMS ask not only the most recent BP but the lowest BP recorded.

Shock index is predictably unreliable in the following circumstances

  1. Altered physiologic compensation (e.g. older patients [9]) – consider *delta shock index
  2. Presence of underlying medical conditions (eg.. undertreated hypertension)
  3. Medication-related disturbances (e.g. B-blockers)

*Delta shock index ≥0.1 predicts increased transfusion requirements and mortality and may be a more useful prognostication tool than shock index, especially in older patients and those with a history of untreated hypertension.

Pitfall: Prehospital hypotension that normalizes without intervention that is ignored. A single prehospital drop in BP may be a clue to impending catastrophic shock.

 

Early actions to consider in the first 15 minutes of trauma resuscitation

  1. Direct pressure/tourniquet on wounds/splint obvious fractures
  2. Bilateral finger thoracostomies
  3. Pelvic binder application
  4. IV tranexamic acid
  5. Blood products/massive transfusion protocol
  6. Call to trauma center – request transfer/retrieval as soon as the need for higher level of trauma care is presumed
  7. Vasopressors only if neurogenic shock suspected

Vascular access in the first 15 minutes of trauma resuscitation

Two short large bore peripheral IVs are recommended for initial vascular access in the trauma patient.

If a peripheral IV cannot be rapidly obtained a humerus IO with pressure bag has adequate infusion rates but should be used only as a bridge to venous access and should be checked frequently for flow.

A central line is not mandatory if two well running peripheral lines are established but should be considered for patients requiring long transport times or when REBOA is being planned.

Volume resuscitation, volume challenge, controlled resuscitation and early resuscitation targets

Consider the following before volume resuscitation. The patient that is bleeding may not appear to be in shock, and the patient who is in shock may not be actively bleeding. Your job is to not only identify shock/occult shock but to identify active bleeding, obstructive and neurogenic shock.

Large volumes of crystalloid contribute to the trauma “triangle of death” (metabolic acidosis, hypothermia and coagulation derangements).

trauma triangle of death

Consider a volume challenge to assess for active occult hemorrhage. 250mL of crystalloid under pressure followed by assessment of signs of perfusion. If a patient transiently responds to 250mL of crystalloid, you may assume active occult hemorrhage. If there is no response consider other causes of shock (obstructive, neurogenic). If you suspect active occult hemorrhage based on severe mechanism (e.g. fall from 7 stories), clinical assessment and/or volume challenge, start blood products ASAP.

Controlled resuscitation (previously termed “permissive hypotension”)[13]. While there are fairly well studied resuscitation targets in the first few hours of trauma resuscitation (urine output, lactate clearance, base deficit etc), there is little to guide us in the first 15 minutes of trauma resuscitation. If there is a delay to starting blood transfusion in a patient presumed to have hemorrhagic shock, consider only small boluses of crystalloid (i.e. 250mL), just enough to maintain adequate tissue perfusion (peripheral pulses present in blunt trauma or central pulses in penetrating injury) and maintain a SBP ≥ 70. For most trauma patients consider targeting this SBP throughout your resuscitation. This approach has been termed “Controlled Resuscitation” and is recommended by our experts a reasonable early resuscitation target. One prospective RCT showed a NNT of 11 for inhospital mortality [13]. Keep in mind the elderly patient, the patient with uncontrolled hypertension at baseline, the patient with a major head injury and the patient with neurogenic shock, may require adjustment in their BP target.

Indications for massive transfusion and resuscitation intensity in trauma resuscitation

Formula to assess which patients need massive transfusion protocol (MTP)

Clinical judgement + Mechanism of injury + Pitfall conditions

It is important to identify early on if your patient requires MTP and the logistics of how to administer it.

Step 1: If the patient is in an obvious shock state, or shock index is >1 [11], or delta shock index is ≥0.1 [16], or has an ABC score ≥ 2* [14], activate the MTP.

Step 2: If none of these are present, consider the resuscitation intensity [19,20]: patients who require 4 units of any combination of crystalloids or blood products to maintain adequate perfusion are considered to have high resuscitation intensity which predicts higher mortality, and should be considered for a MTP.

*ABC score [14]

1 point for each of:  penetrating injury, positive FAST, SBP ≤90, HR ≥120.

A score of ≥2 indicates requirement for activation of MTP

Pitfall conditions – consider a lower threshold for activating MTP

  • Anticoagulation – patients taking anticoagulants are not well represented in MTP studies; have a lower threshold for calling for blood
  • Elderly
  • Medications such as B-blockers

How to give MTP

Give the MTP in balanced blood products 1:1:1 [18]. Although the ratio of red cells to FFP to platelets is meant to be 1:1:1 over the first 24hrs, that does not mean the patient requires FFP and platelets immediately in the ED. Rather, give 4 units of red cells up front as they can usually be delivered faster that FFP and platelets.

Take Home Points for Trauma – The First and Last 15 Minutes Part 1

  • Prepare your team, your gear and yourself prior to patient arrival with 4 discussion points, assigning specific gear preparation to specific team members and mental preparation
  • Resequence the trauma resuscitation by managing massive external hemorrhage and active/dynamic airway first, then concentrating on hemodynamic optimization before definitive airway management in those patients without active/dynamic airways
  • Identify occult shock using shock index >1, delta shock index ≥0.1, the lowest BP recorded, FAST/IVC, a fluid challenge and clinical exam
  • Consider the patient’s age, blood pressure medications and baseline blood pressure in assessing for occult shock, interpreting the shock index and in deciding to activate massive transfusion protocol
  • Early actions to consider include control of massive external hemorrhage, bilateral finger thoracostomies, pelvic binder, tranexamic acid, activation of massive transfusion protocol and call for help
  • Two large bore IVs are the preferred initial access in most trauma patients
  • Avoid transferring a patient long distances with IO access only
  • Large volumes of crystalloid may lead to the “triangle of death”; your goal should be no crystalloid
  • Controlled resuscitation to a target SBP of ≥70 is reasonable in most young, otherwise healthy trauma patients presumed to be in hemorrhagic shock
  • Use clinical judgement, mechanism of injury, pitfall conditions, shock index and resuscitation intensity to help in decisions to activate massive transfusion protocol

Management of trauma arrest Joe Nemeth’s Best Case Ever

Dr. Petrosoniak’s EMU 365 video talk on Massive Transfusion in Trauma

Best Case Ever on What We Can Learn from Prehospital Trauma Management

Episode 39 Trauma Literature Update

Drs. Bosman, Helman, Hicks, Mehta and Petrosoniak have no conflicts of interest to declare.

References

  1. Petrosoniak, A. Hicks, C. Beyond crisis resource management: new frontiers in human factors training for acute care medicine. Curr Opin Anaesthesiol. 2013 Dec;26(6):699-706.
  2. Petrosoniak A, Hicks C. Resuscitation Resequenced: A Rational Approach to Patients with Trauma in Shock. Emerg Med Clin North Am. 2018;36(1):41-60.
  3. Kim WY, Kwak MK, Ko BS, et al. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One 2014;9(11):e112779.
  4. Heffner AC, Swords DS, Neale MN, et al. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation 2013;84(11):1500–4.
  5. Codner P, Obaid A, Porral D, et al. Is field hypotension a reliable indicator of significant injury in trauma patients who are normotensive on arrival to the emergency department? Am Surg 2005;71(9):768–71.
  6. Lipsky AM, Gausche-Hill M, Henneman PL, et al. Prehospital hypotension is a predictor of the need for an emergent, therapeutic operation in trauma patients with normal systolic blood pressure in the emergency department. J Trauma 2006;61(5):1228–33.
  7. Shapiro NI, Kociszewski C, Harrison T, et al. Isolated prehospital hypotension after traumatic injuries: a predictor of mortality? J Emerg Med 2003;25(2):175–9.
  8. Bilello JF, Davis JW, Lemaster D, et al. Prehospital hypotension in blunt trauma: identifying the “crump factor”. J Trauma 2011;70(5):1038–42.
  9. Oyetunji TA, Chang DC, Crompton JG, et al. Redefining hypotension in the elderly: normotension is not reassuring. Arch Surg 2011;146(7):865–9.
  10. King RW, Plewa MC, Buderer NM, et al. Shock index as a marker for significant injury in trauma patients. Acad Emerg Med 1996;3(11):1041–5.
  11. Vandromme MJ, Griffin RL, Kerby JD, et al. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma 2011;70(2):384–8 [discussion: 388–90].
  12. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive Resuscitation during Active Hemorrhage: Impact on InHospital Mortality. J Trauma. June 2002;52(6):1141-46.
  13. Schreiber MA, Meier EN, Tisherman SA, Kerby JD, Newgard CD, Brasel K, Egan D, Witham W, Williams C, Daya M, Beeson J, McCully BH, Wheeler S, Kannas D, May S, McKnight B, Hoyt DB; ROC Investigators. A Controlled Resuscitation Strategy is Feasible and Safe in Hypotensive Trauma Patients: Results of a Prospective Randomized Pilot Trial. J Trauma Acute Care Surg. Apr 2015;78(4):687-95.
  14. Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)?. J Trauma. 2009;66(2):346-52.
  15. Schroll R, Swift D, Tatum D, et al. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury. 2018;49(1):15-19.
  16. Schellenberg M, Strumwasser A, Grabo D, et al. Delta Shock Index in the Emergency Department Predicts Mortality and Need for Blood Transfusion in Trauma Patients. Am Surg. 2017;83(10):1059-1062.
  17. Nascimento B, Callum J, Tien H, et al. Effect of a fixed-ratio (1:1:1) transfusion protocol versus laboratory-results-guided transfusion in patients with severe trauma: a randomized feasibility trial Canadian Medical Association Journal. 2013; 185(12):E583-E589.
  18. Holcomb JB, Tilley BC, Baraniuk S, 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 JAMA. 2015; 313(5):471-478.
  19. Rahbar E, Fox EE, Del junco DJ, et al. Early resuscitation intensity as a surrogate for bleeding severity and early mortality in the PROMMTT study. J Trauma Acute Care Surg. 2013;75(1 Suppl 1):S16-23.
  20. Meyer DE, Cotton BA, Fox EE, et al. A comparison of resuscitation intensity and critical administration threshold in predicting early mortality among bleeding patients: A multicenter validation in 680 major transfusion patients. J Trauma Acute Care Surg. 2018;85(4):691-696.

Now Test Your Knowledge:

1. You are working in a community ED when you are notified that a patient involved in a high-speed MVC is arriving in the next 10 minutes. All of the following are acceptable ways you prepare except:

A. Ensure you have the trauma cart properly stocked and by the bedside

B. Assign specific roles to team members with specific gear preparation for those roles

C. Consider deep breathing exercises, visualization of expected complex tasks and positive self talk to mentally prepare

D. Call for transfer to a trauma center

Answer: D

Team-Based Preparation: 4 Discussion Points

  1. What do we know?
  2. What do we expect to see/What are the possibilities? Run through the most likely immediate life-threatening issues/injuries
  3. What do we do? And discuss contingencies if those actions fail.
  4. Role assignment. Assign logistical tasks to team members.

Ensure that your ED has a trauma cart that contains the gear that you may require, including a pelvic binder, thoracostomy kit, cricothyrotomy kit etc. When assigning roles, assign gear preparation with each role.

Call to a trauma center should typically occur upon completion of the primary survey is complete so that suspected and confirmed injuries can be communicated.

2. In trauma resuscitation you may want to hold off on definitive airway management and address circulation first, except in the following scenario:

A. Neurogenic shock suspected

B. Severe facial trauma

C. Shock index > 1.0

D. Poorly perfused extremities

E. Exsanguination from a limb stab wound

Answer: B

Consider “resuscitate before you intubate” in trauma patients in shock, and procedures to relieve obstructive shock such as bilateral finger thoracostomies and thoracotomy. Focus on physiologic priorities rather than always “ABC”. Tailor your approach to the most severe life-threatening injuries first such as massive external hemorrhage and critical airway compromise. Consider immediate definitive airway if there is dangerous hypoxia or a dynamic airway injury. Severe facial trauma often causes a dynamic airway situation that requires early definitive airway management.

3. A 35-year old male involved in a high-speed MVC is brought into your ED whose thigh is actively bleeding. He is screaming in pain. His vitals include a heart rate of 115, BP of 100/60, respiratory rate of 20 and oxygen saturation of 99% on room air. EMS informs you that he lost several litres of blood at the scene and are concerned for an arterial bleed. Your first step is:

A. Direct pressure +/- tourniquet to the bleeding extremity

B. Assess his airway

C. Calculate a shock index

D. Point of care ultrasound to look for occult hemorrhage

Answer: A

The immediate threats to life must be addressed first, including massive external hemorrhage and airway compromise. In this case, his femur injury is his most immediate threat to life and control/compression of the hemorrhage should be the first step.

4. A 25-year old female involved in a high-speed MVC is brought into your ED. GCS is 15 and her recent vital signs are: HR 100, BP 140/80, SpO2 99% on RA according to EMS. All of the following help you to determine occult shock in the first 15 minutes of resuscitation except?

A. Assessing for adequate peripheral pulses

B. Measuring lactate clearance

C. Asking EMS for the lowest BP that they have recorded

D. Using ultrasound to do a FAST exam

Answer: B

How to assess for occult shock in the first 15 minutes of trauma resuscitation:

  1. Calculate the Shock index (HR/SBP) and/or delta Shock Index; if shock index > 1 or delta Shock Index ≥ 0.1, assume occult shock
  2. Assess the lowest BP measured and trend of BP over time; if isolated or persistent SBP <110, assume occult shock
  3. FAST positive with flat IVC
  4. Feel for the presence of peripheral pulses and look for signs of poorly perfused extremities
  5. Altered LOA in the absence of severe head injury

Although lactate clearance can assess adequacy of tissue perfusion over time, it cannot be assessed in the first 15 minutes of trauma resuscitation, as it takes longer to receive lab results.

5. Shock index (HR/SBP) is predictably unreliable in the following circumstances except:

A. Elderly patients

B. Patients on beta-blockers

C. Patients with uncontrolled hypertension

D. Pediatric patients

E. Spinal shock

Answer: E

Shock index is predictably unreliable in the following circumstances

  1. Altered physiologic compensation (e.g. older patients) – consider delta shock index
  2. Presence of underlying medical conditions (eg. undertreated hypertension)
  3. Medication-related disturbances (e.g. B-blockers)

The shock index cannot be applied to pediatric patients meaningfully. There is a pediatric-adjusted shock index that has been developed.

Shock Index, Pediatric Adjusted (SIPA)

  • 4-6 years = 1.2
  • 6-12 years = 1
  • > 12 years = 0.9

6. A 40-year old female, otherwise healthy, is brought in by EMS after being stabbed in her abdomen several times. She is screaming in pain with a normal oxygen saturation and no evidence of head or neck trauma. Her shock index is >1, but she has strong peripheral pulses, a GCS of 15 and appears to be adequately perfusing her vital organs. You highly suspect intra-abdominal bleeding as a cause for the occult shock. What is your first priority?

A. Activate a massive transfusion protocol and give tranexamic acid IV

B. Give 1L of crystalloid IV under pressure

C. Abdominal CT scan

D. Definitive airway management

Answer: A

Formula to assess which patients need massive transfusion protocol (MTP): Clinical judgement + Mechanism of injury + Pitfall conditions

Step 1: If the patient is in an obvious shock state, or shock index is >1, or delta shock index is ≥0.1, or has an ABC score ≥ 2*, activate the MTP.

*ABC score: 1 point for each of:  penetrating injury, positive FAST, SBP ≤90, HR ≥120. A score of ≥2 indicates requirement for activation of MTP.

Tranexamic acid should be strongly considered whenever a patient requires blood products as early as possible in the trauma resuscitation.

Large crystalloid volumes in patients with internal bleeding put patients at risk for the “triangle of death” – metabolic acidosis, hypothermia and coagulation abnormalities.

7. An 80-year old male is brought in by EMS after a deep stab wound to the abdomen. He has a history atrial fibrillation and CHF, and is taking Xarelto and metoprolol. His shock index is 1.0 and no signs of decreased organ perfusion and no airway issues. What is your next step?

A. Start with 1 unit of red cells and strongly consider activating a massive transfusion protocol

B. Give 1L of crystalloid

C. Use ultrasound to assess the IVC for volume status and need for fluids/blood products

D. Send him to the CT scanner to look for vascular injury

Answer: A

Although this patient is not in an obvious shock state, he has a borderline shock index and he has a number of pitfall conditions (beta-blocker, anticoagulation) to consider a low threshold for activating MTP. In addition, he has a concerning mechanism of injury for hemorrhagic shock.

Formula to assess which patients need massive transfusion protocol (MTP): Clinical judgement + Mechanism of injury + Pitfall conditions

Step 1: If the patient is in an obvious shock state, or shock index is >1, or delta shock index is ≥0.1, or has an ABC score ≥ 2*, activate the MTP.

Step 2: If none of these are present, consider the resuscitation intensity: patients who require 4 units of any combination of crystalloids or blood products to maintain adequate perfusion should be considered for a MTP.

*ABC score: 1 point for each of:  penetrating injury, positive FAST, SBP ≤90, HR ≥120. A score of ≥2 indicates requirement for activation of MTP

Pitfall conditions – consider a lower threshold for activating MTP:

  • Anticoagulation
  • Elderly
  • Medications such as B-blockers

8. You have decided to activate massive transfusion protocol (MTP) for your young adult, otherwise healthy polytrauma patient in your small community hospital. The patient’s blood pressure is 90/60 and there are no signs of inadequate tissue perfusion. Blood products should be given in the following fashion:

A. 1 unit of pRBC, 1 of platelets, and 1 of FFP concurrently

B. 4 units of pRBC upfront then catch up later with the other blood products with 1:1:1 in mind so that in the first 24 hours a balanced transfusion has been given

C. Tranexamic must be given before red cell transfusion

D. Start with 250cc bolus of crystalloid even if the blood is ready, to look for a clinical response

Answer: B.

Give the MTP in balanced blood products 1:1:1. Give 4 units of red cells up front as they can almost always be delivered faster that FFP and platelets. If there is a delay to starting blood transfusion in a patient with hemorrhagic shock, consider only small boluses of crystalloid (i.e. 250mL), to maintain tissue perfusion and a SBP ≥ 70. Keep in mind the elderly patient, the patient with uncontrolled hypertension at baseline, the patient with a major head injury and the patient with spinal shock, may require adjustment in their BP target.

9. You are attempting to secure 2 peripheral IVs in your trauma patient with a shock index >1, but after 1 attempt on each arm, the nurses tell you an IV cannot be obtained. What is your next best step?

A. Ask the nurse to try 2 more times to obtain peripheral IV access

B. Obtain a tibial IO immediately

C. Obtain a humerus IO and then continue to attempt IV access

D. Obtain a central line

Answer: C

Two short large bore peripheral IVs are recommended for initial vascular access in the trauma patient. If a peripheral IV cannot be rapidly obtained a humerus IO with pressure bag has adequate infusion rates but should be used only as a bridge to venous access and should be checked frequently for flow. Humerus infusion rates have been shown to be faster than tibial infusion rates and so are therefore preferred in hemodynamically unstable patients without a contraindication to a humeral IO. A central line is not mandatory if two well running peripheral lines are established but should be considered for patients requiring long transport times or when REBOA is being planned.

10. Consider all of the following in the first 15 minutes of trauma resuscitation except:

A. Bilateral finger thoracostomies in patients without an identifiable cause for shock

B. Pelvic binder application in patients without an identifiable cause for shock

C. 1.5L Ringer’s Lactate IV bolus under pressure in patients without an identifiable cause for shock

D. IV tranexamic acid in patients without an identifiable cause for shock

Answer: C

Early actions in the first 15 minutes include:

  1. Direct pressure/tourniquet on wounds/splint obvious fractures
  2. Bilateral finger thoracostomies
  3. Pelvic binder application
  4. IV tranexamic acid
  5. Blood products/massive transfusion protocol
  6. Call to trauma center – request transfer/retrieval as soon as the need for higher level of trauma care is presumed
  7. Vasopressors only if neurogenic/spinal shock suspected

Large volumes of crystalloid contribute to the trauma “triangle of death” (metabolic acidosis, hypothermia and coagulation derangements).

Consider a volume challenge to assess for active occult hemorrhage. 250mL of crystalloid under pressure followed by assessment of signs of perfusion. If there is no response consider other causes of shock (obstructive, spinal). If you suspect active occult hemorrhage start blood products ASAP.