Initial Care of the Severely Injured Patient N Engl J Med 2019; 380:763-770 DOI: 10.1056/NEJMra1609326

1. Initial Care of the
Severely Injured Patient
N Engl J Med 2019; 380:763-770
DOI: 10.1056/NEJMra1609326

2. d
“He who would become a surgeon should
join an army and follow it.”
- Hippocrates 460 – 370 BC.

3. MANAGEMENT OF SEVERE SEPSISApproach to the Care
of Severe Injury
Tourniquet Tranexamic Acid
Permissive
Hypotension
Damage-Control
Surgery
The Golden Hour High-Ratio Massive
Transfusion
Ultrasonography REBOA

4. Tourniquet

5. Use field tourniquets for life-threatening
extremity hemorrhage resulted in a
demonstrable reduction in deaths from
extremity exsanguination
Advanced topical hemostatic dressings
were also introduced to control limb and
junctional exsanguination.

9. Tactical Combat Casualty
Care Guidelines
31 JAN 2017

10. Use one or more CoTCCC-recommended
limb tourniquets if necessary.
Use a CoTCCC approved hemostatic
dressing for compressible hemorrhage not
amenable to limb tourniquet use.
If the first tourniquet does not control
bleeding after tightening, then add a
second tourniquet side-by-side with the
first.

11. Convert Limb tourniquets and junctional
tourniquets if the following three criteria are
met:
– The casualty is not in shock.
– It is possible to monitor the wound closely for
bleeding.
– The tourniquet is not being used to control
bleeding from an amputation.
Convert tourniquets in less than 2 hours if
bleeding can be controlled with other means.
Expose and use an indelible marker to clearly
mark all tourniquet sites with the time of
tourniquet application, reapplication,
conversion, or removal.

13. Tranexamic Acid
(Anti-fibrinolysis)

14. Tranexamic Acid 1 g administered as an IV
bolus over 10 minutes, followed by a 1-g
IV infusion over 8 hours, with the first
dose given within 3 hours after injury.

15. Time-sensitive
As early as possible after injury
Incorporated into massive-transfusion
programs

18. TXA safely reduced the risk of death in bleeding trauma
patients in this study.
On the basis of these results, TXA should be considered for
use in bleeding trauma patients.

20. TXA reduces death due to bleeding in women with PPH
with no adverse effects.

21. When used as a treatment for PPH, TXA should be given as
soon as possible after bleeding onset.

27. Permissive
Hypotension

28. “Inaccessible or uncontrolled sources of
blood loss should not be treated with
intravenous fluids until the time of
surgical control.”
- Walter Cannon 1871 – 1945

29. The common practice of administering
2 L of crystalloid fluid in hypotensive
trauma patients worsens
coagulopathy and acidosis and
should be abandoned.

30. Normotensive patients should receive
no fluid resuscitation
Hypotensive patients should have
fluid resuscitation withheld until SBP
approaches 80 mmHg, small-volume
boluses of blood or plasma (250 to
500 ml) should be given to maintain
SBP between 80 and 90 mmHg.
Traumatic brain injury

31. Damage-Control
Surgery

32. Damage-control surgery is a technical
strategy to control massive bleeding.
“Staged” surgery
Definitive surgery
Between surgical stages, patients are
placed in the ICU, where their
physiological status is carefully
managed, with attention to
resuscitation, resolution of acidosis,
maintenance of normothermia, and
elimination of coagulopathy.

33. The Golden Hour

34. The primary purpose of the golden
hour concept is to drive all efforts
toward early hemorrhage control,
including initial care, triage, rapid
evacuation, and resuscitation.
Focus on surgical hemorrhage control.

36. High-Ratio
Massive
Transfusion

37. Whole blood
Component therapy
Massive-transfusion protocol:
high ratio of pRBC to FFP (1:1)

38. Blood products should be administered at
as high a rate as possible (often as fast as
500 ml per minute) in order to obey the
principles of hypotensive resuscitation,
with a target SBP of 80 mmHg during
damage-control surgery.
Resuscitation is not a substitute for
hemorrhage control. If resuscitation is
initiated, the damage-control surgical
interventions should be initiated
simultaneously.

39. Ultrasonography
(FAST)

40. REBOA
Resuscitative
Endovascular
Balloon
Occlusion of the
Aorta

41. To control non-compressible, intra-
cavitary hemorrhage below the
diaphragm.
Less invasive alternative to
emergency thoracotomy and aortic
cross-clamping for a patient who is
hemodynamically compromised but
does not have evidence of thoracic
hemorrhage and is not in arrest.

42. Zone I: temporarily control
infra-diaphragmatic
hemorrhage in the absence
of supra-diaphragmatic
hemorrhage.
Zone III: temporarily control
massive pelvic or junctional
hemorrhage in the absence
of supra-diaphragmatic and
intra-abdominal hemorrhage.

43. Abdominal visceral ischemia limits the
occlusion time to less than 30 minutes,
but ideally, the occlusion time should be as
short as possible.
The dangers of REBOA include total
visceral ischemia, lower-limb loss,
exacerbation of traumatic brain injury,
spinal cord ischemia, and rapid proximal
blood loss.

45. Brenner M, et al. Trauma Surg Acute Care Open 2018;3:1–3.
doi:10.1136/tsaco-2017-000154

46. Indications for REBOA
Guidelines for REBOA use and
implementation
Transfer of patients
Management of the patient with REBOA

47. MANAGEMENT OF SEVERE SEPSISApproach to the Care
of Severe Injury
Tourniquet Tranexamic Acid
Permissive
Hypotension
Damage-Control
Surgery
The Golden Hour High-Ratio Massive
Transfusion
Ultrasonography REBOA

48. Q & A