Surgical control of bleedingSurgical control of bleeding should be considered in patientswith uncontrolled hemorrhage presenting with haemorrhagicshock with identified source of bleed (Grade 1B) and the timefor this should be minimized in order to prevent mortalityrelated to trauma as more than 50% of all trauma patientswith a fatal outcome die within 24 h of injury.16Local hemostatic agentsUse of local hemostatic agents like collagen, gelatin and cellulosebased products, fibrin and synthetic glues should beconsidered along with other surgical methods in patients withblunt trauma abdomen presenting with parenchymal injuriesand associated uncontrolled hemorrhage (Grade 1B).16,18Further assessmentPatients presenting with haemorrhagic shock with unidentifiedsource of bleeding should undergo rapid examinationby Focused assessment with sonography for trauma (FAST)in order to detect the source of bleeding (Grade 1B).19 FASTis a rapid study utilized to identify hemorrhage. In FASTultrasound technology is used by properly trained individualsto detect the presence of haemoperitoneum. Withspecific equipment and experienced hands, ultrasound hasa sensitivity, specificity, and accuracy in detecting intraabdominalfluid comparable to direct peritoneal lavage(DPL). Thus, ultrasound provides a rapid, noninvasive, accurate,and inexpensive means of diagnosing haemoperitoneumthat can be repeated frequently. Furthermore,ultrasound can detect one of the nonhypovolemic reasonsfor hypotension: pericardial tamponade. Scans are obtainedof the pericardial sac, hepatorenal fossa, splenorenal fossaand pelvis or pouch of douglas. Patients who are hemodynamicallystable should be further assessed by use of CTscans (Grade 1B).16Shock-hypoperfusionSerum lactate and base deficit measurements are excellentpredictors to assess the severity of bleeding, resultant shockand hypoperfusion. Changes in lactate concentrations havebeen shown to provide an early and objective evaluation of apatient’s response to therapy and repeated lactate determinationshave proved to be a reliable prognostic index forpatients with hemorrhagic shock.20 Early return of lactatelevels to normal levels (<2 mmol/l) within 24 h has beenproved to be associated with improved outcomes in terms ofmortality. A significant correlation has been established betweenthe admission base deficit and transfusion requirementswithin the first 24 h and the risk of post-traumaticorgan failure or death.21Fluid resuscitation to correct shockCrystalloids should be used to correct shock with a targetmean arterial pressure of not more than 65 mmHg in patientswith no evidence of traumatic brain injury (Grade 1A).Higher blood pressure targets requiring large volumes ofTable 2 e Grading of recommendation.Grade of recommendation Clarity of risk/benefit Quality of supporting evidence Implications1AStrong recommendation,high-quality evidenceBenefits clearly outweighrisk and burdens, or viceversaRCTs without important limitationsor overwhelming evidence fromobservational studiesStrong recommendation, can applyto most patients in most circumstanceswithout reservation1BStrong recommendation,moderate-qualityevidenceBenefits clearly outweighrisk and burdens, or viceversaRCTs with important limitations(inconsistent results, methodologicalflaws, indirect or imprecise) orexceptionally strong evidence fromobservational studiesStrong recommendation, can applyto most patients in most circumstanceswithout reservation1CStrong recommendation,low-quality or very lowqualityevidenceBenefits clearly outweighrisk and burdens, or viceversaObservational studies or case series Strong recommendation but maychange when higher quality evidencebecomes available2AWeak recommendation,high-quality evidenceBenefits closely balancedwith risks and burdenRCTs without important limitationsor overwhelming evidence fromobservational studiesWeak recommendation, best actionmay differ depending on circumstancesor patients’ or societal values2BWeak recommendation,moderate-qualityevidenceBenefits closely balancedwith risks and burdenRCTs with important limitations(inconsistent results, methodologicalflaws, indirect or imprecise) orexceptionally strong evidence fromobservational studiesWeak recommendation, best actionmay differ depending on circumstancesor patients’ or societal values2CWeak recommendation,Low-quality or very lowqualityevidenceUncertainty in theestimates of benefits, risksand burden; benefits, riskand burden maybe closely balancedObservational studies or case series Very weak recommendation; otheralternatives may be equally reasonable166 medical journal armed forces india 70 (2014) 163 e169fluid may increase hydrostatic pressure, thereby dislodgingthe clot, can produce dilution coagulopathy and make thepatient cold which could be detrimental. The incidence ofcoagulopathy has been found to increase by 40% in patientsreceiving 2 L of fluid to about 70% in patients receiving 4 L offluids.22 It is prudent to limit use of fluids to small alliquotsof 250 ml of crystalloids (Ringer Lactate) to keep the radialpulse palpable (systolic blood pressure > 80 mmHg) and thepatient conscious and oriented. In a patient with traumaticbrain injury (TBI), a higher systolic blood pressure of100 mmHg is recommended to maintain the cerebralperfusion pressure. Colloids should be used within its prescribedlimits in patients who are hemodynamically unstableas the colloid solutions notably starch basedsolutions can precipitate coagulopathy and renal failure.Hypertonic saline may have a role in traumatic brain injury(TBI).Assessment of coagulationConventional coagulation screens which include INR, APTT,Platelet counts, Fibrinogen levels and assessment of initial
clotting factors, clot strength, fibrin concentrate, platelet
function and the rate of fibrinolysis should be assessed by
thrombelastography. An increase in INR and APTT of more
than 1.5 times and 5 min clot amplitude of less than 36 mm on
thromboelastography (TEG) is diagnostic of acute traumatic
coagulopathy.
Blood and blood products
Packed red blood cell (PRBC) and fresh frozen plasma (FFP)
In order to maintain tissue oxygen delivery and restore an
effective coagulation, early administration of PRBCs and fresh
frozen plasma is recommended (Grade 1B). The administration
of red blood cells is considered indispensable when the
Hb levels are less than 7 g%.
The administration of fresh frozen plasma should be as
early as possible with transfusion of PRBCs in order to
compensate for the deficit in coagulation factors and also to
prevent dilutional coagulopathy. FFP transfusion is recommended
when APTT and INR are1.5 times the normal. The
most frequently recommended initial dose is 10e15 ml/kg
and further doses should be based on coagulation
parameters.
Though several recent studies have highlighted the
importance of high PRBC:FFP ratio (ratio of approximately
1:1), these studies have a potential for survival bias (patients
who have died early are more likely to have received
a higher PRBC:FFP ratio). Thus the optimal value of
PRBC:FFP ratio remains controversial. Because FFP requires
a significant amount of time before it is thawed and available
for transfusion and many trauma deaths occur soon
after hospital admission, patients who die early may
receive RBC units but die before FFP therapy has begun. The
PRBC:FFP ratio is an important element in early PRBC and
FFP transfusion, but the time at which the FFP transfusion
has begun would determine the outcome in terms of mortality
rather than the ratio of PRBC to FFP.23,24 The role of
whole blood is limited to the military setting where walking
blood banks are created. In civilian practice whole blood
has no role due to the concern of transmission of viral
infections.
Platelet transfusion
Platelets should be transfused to maintain a blood platelet
count of more than 50,000/cumm in trauma patients and more
than 100,000/cumm in patients with traumatic brain injury
(Grade 1C).25
Fibrinogen concentrate and cryoprecipitate
As a precursor of clot formation, fibrinogen plays a major
role in coagulation function. Fibrinogen deficiency is linked
to uncontrolled bleeding and compromised survival. Hypo-
fibrinogenemia is an important part of trauma associated
coagulopathy. The use of fibrinogen concentrate and cryoprecipitate
is recommended when the plasma fibrinogen
level falls below1.5e2.0 g/l or when there is a thromboelastometric
evidence of functional fibrinogen deficiency
(Grade 1C).16 An initial fibrinogen concentrate dose of 3e4 g
or 50 mg/kg of cryoprecipitate, which is approximately
equivalent to 15e20 units in a 70 kg adult and further doses
based on thromboelastometric analysis is recommended
(Grade 2C).16
Antifibrinolytics
Hyperfibrinolysis is an important contributor to trauma
induced coagulopathy. Fibrinolysis greater than 3% as
measured by thromboelastometry is the critical value for
initiation of antifibrinolytic therapy.26 Tranexamic acid has
been found to reduce the transfusion requirements and
improve mortality in trauma patients.16,27.
The use of tranexamic
acid with a loading dose of 1 g over 10 min followed
by 1 g over 8 h is recommended (Grade 1A). The use of drug in
the early period within 3 h of trauma has been found to be
beneficial and no improvement in outcome has been found
when used after 3 h27
Role of recombinant factor VIIa (rFVIIa)
Recombinant factor VIIa is not the first line treatment in
bleeding trauma patients. Since FVIIa acts on patient’s own
coagulation system, there must be adequate number of
platelets and fibrinogen levels available for it to cause
thrombin burst.28 The efficacy of rFVIIa as a pro-hemostatic
agent and to stop bleeding also varies widely with the physiological
state of the body like core body temperature and
acidosis. Decrease in body temperature up to 33 C
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