2. Airway
Patients with (or at risk from) airway compromise
should be intubated prior to transfer
The tracheal tube should be secured and confirmed in
correct position
3. Breathing
Patient adequately sedated if ventilated
Ventilation established (and stable) on transport
ventilator
Adequate gas exchange on transport ventilator
confirmed by arterial blood gas analysis
Adequate oxygen supply on transfer vehicle
4. Circulation
Adequate intravenous access
Circulating volume optimized
Hemodynamically stable
All lines are patent and secured
Any active bleeding controlled
Long bone/pelvic fractures stabilized
ECG and blood pressure monitored
5. C. Spine
Adequate spinal immobilization (if indicated)
Disability
No active seizures
Initial treatments for raised intracranial pressure (if
indicated)
Life-threatening electrolyte disturbances corrected
Blood glucose >70 mg/dl
9. Resuscitation protocol in traumatic hemorrhagic shock
General principle:
Traumatic death is the main cause of life years lost worldwide.
Hemorrhage is responsible for almost 50% of deaths in the first
24 h after trauma.
The optimal resuscitative strategy is controversial:
Choice of fluid
Target of hemodynamic goals for hemorrhage control
The optimal prevention of traumatic coagulopathy are questions.
10. Fluid resuscitation
I. Type of fluid
Lactated Ringer’s solution is recommended as first-
line resuscitation fluid in trauma patients
Albumin should be avoided in patients with TBI
In patients with TBI, isotonic saline should be
preferred over hypotonic fluids because it can reduce
the risk of cerebral edema.
11. II. Endpoints of resuscitation
Three different target systolic blood pressure values can be
considered for three different traumatic conditions before
controlling source of hemorrhage:
60–70 mmHg for penetrating trauma
80–90 mmHg for blunt trauma without TBI
100–110 mmHg for blunt trauma with TBI
Lactate ≥ 2 mmol/L and base deficits ≥ -5 mEq/L have been
demonstrated useful to stratify patients who need a larger
amount of fluid after the initial resuscitation.
12. III. Vasopressor
Early use of norepinephrine could limit fluid
resuscitation and hemodilution.
The dose of norepinephrine should be titrated until we
reach the target systolic blood pressure as indicated
above
13. IV. Transfusion and prevention of acute
coagulopathy of trauma
The correction and prevention of traumatic coagulopathy
have become central goals of early resuscitative
management of hemorrhagic shock.
a) Red blood cells
In patients without TBI: Target haemoglobin level (7-9
g/dL)
In patients with severe TBI (GCS ≤ 8): Target haemoglobin
level ≥ 10 g/dL
14. a) Fresh Frozen Plasma (FFP)
In all patients FFP should be considered when PT or
PTT ≥ 1.5 times normal value
The initial recommended dose of FFP is 10 to 15 ml/kg
15. b) Platelet
In patients without TBI: Platelet transfusion is
recommended when platelet count ≤ 50.000/L
In patients with TBI: Platelet transfusion is
recommended when platelet count ≤ 100.000/L
16. c) Fibrinogen
In all patients, fibrinogen level should be maintained ≥ 150-200
mg/dL
If The use of FFP failed to rapidly correct the
hypofibrinogenemia
Resuscitation with 10 to 15 mL/kg of FFP only increased the
fibrinogen plasma level to 40 mg/dL
More than 30 mL.kg of FPP should be necessary to increase the
fibrinogen plasma level to 100 mg/dL
Ten single bags of cryoprecipitate derived from whole blood are
needed to raise the plasma fibrinogen level by 100 mg/dL
17. d) Adjuvant Therapy
I. Tranxemic acid: routine administration of tranexamic acid
(loading dose of 1 g over 10 min, then infusion of 1g over 8 hr) in
patients with hemorrhagic shock was associated with a
decreased mortality rate.
II. Factor VIIa: No clear recommendation to use activate factor
VII and the use of this factor should be discussed on a case-by-
case basis.
III. Ionized calcium level should be maintained between 1.1-1.3
mmol/L
