A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients

Schreiber, Martin A.; Meier, Eric N.; Tisherman, Samuel A.; Kerby, Jeffrey D.; Newgard, Craig D.; Brasel, Karen J.; Egan, Debra; Witham, William R.; Williams, Carolyn; Daya, Mohamud; Beeson, Jeff; McCully, Belinda H.; Wheeler, Stephen; Kannas, Delores; May, Susanne; McKnight, Barbara; Hoyt, David B.

doi:10.1097/ta.0000000000000600

Cited by 156 publications

(127 citation statements)

References 38 publications

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“…22 Several clinical studies have shown either improved outcome 23 or no difference 24,25 in civilian patients randomized to hypotensive versus normotensive resuscitation. However, these studies were performed in urban environments where prehospital transport times are relatively short.…”

Section: Remote Damage Control Resuscitation (Rdcr)mentioning

confidence: 99%

Remote Damage Control Resuscitation in Austere Environments

Chang

Eastridge

Holcomb³

2017

Wilderness & Environmental Medicine

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Hemorrhage is the leading cause of preventable military and civilian trauma death. Damage control resuscitation (DCR) with concomitant mechanical hemorrhage control has become the preferred in-hospital treatment of hemorrhagic shock. In particular, plasma-based resuscitation with decreased volumes of crystalloids and artificial colloids as part of DCR has improved outcomes in the military and civilian sectors. However, translation of these principles and techniques to the prehospital, remote, and austere environments, known as remote damage control resuscitation or RDCR, is challenging given the resource limitations in these settings. Rapid administration of tranexamic acid and reconstituted freeze-dried (lyophilized) plasma as early as the point of injury are feasible and likely beneficial, but comparative studies in the literature are lacking. Whole blood is likely the best fluid therapy for traumatic hemorrhagic shock, but logistical hurdles need to be addressed. Rapid control of external hemorrhage with hemostatic dressings and extremity tourniquets are proven therapies, but control of non-compressible hemorrhage (i.e. torso hemorrhage) remains a significant challenge.

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Section: Remote Damage Control Resuscitation (Rdcr)mentioning

confidence: 99%

Remote Damage Control Resuscitation in Austere Environments

Chang

Eastridge

Holcomb³

2017

Wilderness & Environmental Medicine

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“…52 A multicenter pilot trial by ROC randomized 192 prehospital hypotensive trauma patients to high (110 mmHg) and low (70 mmHg) SBP goals and reported improved 24-hour survival in the low SBP group after blunt trauma (97% versus 82%), but no difference after penetrating trauma (81% versus 81%). 53 Significantly, all of the randomized trials cited above excluded patients with significant head injury.…”

Section: Pharmacologic Treatment Optionsmentioning

confidence: 99%

Optimal Fluid Therapy for Traumatic Hemorrhagic Shock

Chang¹,

Holcomb²

2017

Critical Care Clinics

112

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The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.

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“…Schreiber et al performed a randomized pilot trial to compare the effect of controlled resuscitation (CR) with standard resuscitation (SR) in the pre-hospital scene [38] ( Table 2). The mean (standard deviation) crystalloid volume administered during the pre-hospital period was 1.0 (1.5) L in the CR group and 2.0 (1.4) L in the SR group.…”

Section: Clinical Trials Examining Restricted/controlled Resuscitationmentioning

confidence: 99%

Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in patients with severe trauma

2017

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Achieving a balance between organ perfusion and hemostasis is critical for optimal fluid resuscitation in patients with severe trauma. The concept of "permissive hypotension" refers to managing trauma patients by restricting the amount of resuscitation fluid and maintaining blood pressure in the lower than normal range if there is continuing bleeding during the acute period of injury. This treatment approach may avoid the adverse effects of early, high-dose fluid resuscitation, such as dilutional coagulopathy and acceleration of hemorrhage, but does carry the potential risk of tissue hypoperfusion. Current clinical guidelines recommend the use of permissive hypotension and controlled resuscitation. However, it is not mentioned which subjects would receive most benefit from this approach, when considering factors such as age, injury mechanism, setting, or the presence or absence of hypotension. Recently, two randomized clinical trials examined the efficacy of titrating blood pressure in younger patients with shock secondary to either penetrating or blunt injury; in both trials, overall mortality was not improved. Another two major clinical trials suggest that controlled resuscitation may be safe in patients with blunt injury in the pre-hospital setting and possibly lead to improved outcomes, especially in patients with pre-hospital hypotension. Some animal studies suggest that hypotensive resuscitation may improve outcomes in subjects with penetrating injury where bleeding occurs from only one site. On the other hand, hypotensive resuscitation in blunt trauma may worsen outcomes due to tissue hypoperfusion. The influence of these approaches on coagulation has not been sufficiently examined, even in animal studies. The effectiveness of permissive hypotension/ hypotensive resuscitation and restricted/controlled resuscitation is still inconclusive, even when examining systematic reviews and meta-analyses. Further investigation is needed to elucidate the effectiveness of these approaches, so as to develop improved treatment strategies which take into account coagulopathy in the pathophysiology of trauma.

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A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients

Cited by 156 publications

References 38 publications

Remote Damage Control Resuscitation in Austere Environments

Remote Damage Control Resuscitation in Austere Environments

Optimal Fluid Therapy for Traumatic Hemorrhagic Shock

Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in patients with severe trauma

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