Introduction

Hemorrhage results from disruption of the blood vessel wall (i.e., vascular trauma). Early and effective management of this injury including control of the bleeding and replacement of blood volume are imperative for survival. The wise surgeon understands that recent advances in the field make proper resuscitation every bit as important as any operative maneuver to expose and control a blood vessel or intricately reconstruct a vascular injury. Without knowing and adhering to this modern approach to resuscitation, the patient will be dead or needlessly compromised.

Hypovolemia from inadequately controlled hemorrhage has been identified as a leading cause of avoidable death in both the prehospital and in-hospital civilian settings. In the wartime environment, where explosion-related and gunshot wounds predominate, the extremities are the most commonly injured body regions. While death from extremity hemorrhage has been a leading cause of death historically, the modern broad distribution and appropriate use of tourniquets and topical hemostatic agents have reversed this trend. A landmark analysis of cause of death during a decade of war in Afghanistan and Iraq reported that noncompressible bleeding in the torso (i.e., thorax, abdomen, pelvis) was the most frequent cause of potentially preventable death (67%), while mortality from extremity hemorrhage was relatively uncommon (14%).

As discussed in Chapter 8 , the term “potentially preventable” death refers to mortality occurring in those who had no lethal head or cardiac wounds or body disruption from explosive injury. In effect, such individuals died from uncontrolled bleeding and unmitigated hemorrhagic shock. The importance of coagulopathy following vascular trauma and hemorrhage has become more apparent and has influenced a profound change in military medical strategy of when blood products are first administered, the ratio in which they are administered, how coagulopathy is dynamically monitored, and how product replacement is tailored to the need. These changes, which have substantial potential for strategic impact on national blood product usage if adopted from military experience, are highlighted in this chapter.

It is now acknowledged that surgery does not follow resuscitation but is an intrinsic part of resuscitation. This chapter explains how a trauma team and a hospital can be optimally configured to facilitate rapid surgical intervention for noncompressible hemorrhage that causes critical hypovolemia. This requires working across traditional medical boundaries, whether these boundaries are physical or cultural. Operative intervention, open or endovascular, is not always required as part of resuscitation following vascular trauma, particularly in the setting of blunt trauma and closed injuries (e.g., high-grade, solid organ injury). In these scenarios initial management is more often directed at detailed diagnosis and nonoperative stabilization. The challenge in the hospital lies in staff being able to identify those patients who demand rapid operative intervention and in the facility being flexible to respond. The UK’s traditional network of district general hospitals (with relatively low trauma workload that is principally of blunt injury) was a model that responded poorly to the need for immediate surgical intervention. This structural disadvantage has been remedied by emergence of regional major trauma centers in the United Kingdom, stimulated by evidence of nationwide systemic underperformance in 2007.

This chapter will focus unapologetically on the trauma team and hospital approach to vascular trauma and resuscitation. However, the chapter will introduce important and recent prehospital developments (which will be more completely described in Chapter 15 by Blackbourne and Butler) that are targeted at controlling bleeding and minimizing coagulopathy. Resuscitation end points are suggested in this chapter; these can provide a handrail in a complex clinical scenario. The ethics of hospital-based resuscitation are also covered (e.g., when it may not be appropriate to star, and when it is appropriate to stop), recognizing that these decisions are more pressing when resources (clinicians, operating-theater capacity, intensive-trauma-unit [ITU]or intensive-care-unit [ICU] capacity, blood products) are constrained.

Definitions

Damage control resuscitation (DCR) is a relatively new term that reflects advances in combat casualty care made in the wars in Afghanistan and Iraq. This practice has evolved as an overarching concept that draws together all those interventions, including operative intervention, that aim to reduce bleeding from vascular disruption, to optimize oxygenation, and to improve outcome. It therefore starts with first aid measures (including the use of a tourniquet or topical hemostatic agent) rendered at the point of injury and finishes with the postoperative management of coagulopathy on the intensive care unit. In this context, damage control resuscitation spans the spectrum of vascular trauma management. DCR is formally defined as “a systemic approach to major trauma combining the <C>ABC (catastrophic bleeding, airway, breathing, circulation) paradigm with a series of clinical techniques from point of wounding to definitive treatment in order to minimize blood loss, maximize tissue oxygenation, and optimize outcome.”

Damage control surgery (DCS) therefore fits within DCR. Specifically, DCS has come to mean a time-limited surgical procedure (i.e., abbreviated operation) where the imperative is the minimal intervention to save life and limb before hypothermia, coagulopathy, and acidosis demand intensive care or result in demise. Specific aspects of damage control surgery as they relate to the management of vascular trauma are discussed in Section 4.

In contrast to damage control surgery, it is incorrect to consider DCR a time-limited, resource-limited, or intervention-limited phenomenon; in fact, the opposite is true. DCR incorporates prehospital intervention (including blood-product administration), massive transfusion immediately on arrival at the hospital (see Hemostatic Resuscitation in this chapter) and consultant-based, multidisciplinary team resuscitation in the operating theater. (See the discussion on three-dimensional [3-D] resuscitation later in this chapter.) Initially, “damage control” was a maritime term that related to the emergency control of situations that may risk the sinking of a ship. In this respect, DCR incorporates a patchwork of interventions that collectively provides an effective plug to blood loss (mechanically and hematologically), thereby keeping the patient “afloat.”

Resuscitation Paradigms

The American College of Surgeons’ Committee on Advanced Trauma Life Support (ATLS) program has provided an international standard for trauma resuscitation for almost 30 years. This is underpinned by the mantra of ABC—airway, breathing, and circulation—with a strong emphasis on concomitant cervical spine control following severe blunt trauma. Although a raft of parallel specialist resuscitation programs have been developed (e.g., for burns, children, neonates), the ABC paradigm has endured.

Historically, medicine advances in war and 21st-century conflicts in Iraq and Afghanistan have supported this truism, with particular respect to resuscitation. What has been challenged is the ABC paradigm; and, for the military, this has been replaced by <C>ABC, where <C> stands for “catastrophic hemorrhage” or “control of catastrophic hemorrhage” from vascular disruption. This change concentrates the effort on stopping external bleeding within the first few minutes of injury and empowers those at the point of injury with skills and equipment. This new paradigm has resonated in a change of approach from first aid through hospital-based resuscitation and has driven incremental amendments to organization, guidelines, training, and equipment. While it is difficult to evaluate the impact of change at any given level in this chain of care, there is robust evidence of the systemic impact of these strategies in reducing preventable death from trauma (i.e., producing a cohort of unexpected survivors). <C>ABC is therefore working in the setting of wartime vascular trauma and hemorrhage to improve outcomes. Furthermore, there is increasing sentiment and evidence that aspects of these hemorrhage control and resuscitation strategies are translating to care of injured civilians.

Horizontal Versus Vertical Resuscitation

The ATLS material teaches a prioritized, linear approach to resuscitation for the clinician forced to work in isolation: airway with cervical spine control, then breathing, then circulation. This vertical approach poorly reflects the reality in most hospitals where resuscitation is team based, that is, where multiple priorities are managed in parallel or in a horizontal manner. The patient who needs anesthetic as part of managing a compromised airway (A) first needs an intravenous cannula inserted (C) in order to administer the necessary medication and may well require concomitant preparation for insertion of a chest drain (B) to treat a pneumothorax that would otherwise worsen and cause tension physiology once positive pressure ventilation began.

A horizontal approach to successful resuscitation requires leadership. In many countries, trauma team leadership is provided by a surgeon; in the United Kingdom, the norm is an emergency physician. The background of training is less important than the required judgment that stems from experience, the interpersonal skills to coordinate multidisciplinary team members and the authority to make decisions that affect how the patient is to be investigated and treated. The type of leadership will vary with the experience of the team. An inexperienced team needs to be managed directly with clear and authoritative instruction, whereas an experienced team benefits more from a coach or supporter. Rarely, a team may be so well rehearsed that individuals need no direction and the team is self-managing: one fairly appropriate analogy is the required coordination of a Formula 1 pit crew. In some instances the team leader may become more of a mentor who will step back from the specific steps occurring within the resuscitation. This scenario is particularly useful when there are multiple casualties and where the consultant physician is able to manage competing priorities related to diagnostic imaging, procedures or interventions, and patient disposition.

Three-Dimensional Versus Two-Dimensional Resuscitation

Even though a team-based approach removes the requirement for a stepwise, linear resuscitation, the overall process for the management of vascular trauma is often linear or two-dimensional (2-D). Specifically, there is an initial assessment and treatment in the emergency department (ED); then imaging, often in a separate location; followed by operative intervention (DCS) and stabilization in an intensive care unit. For the sake of efficiency, casualties should flow in one direction; but experience demonstrates that, on occasion, patients return to the ED after imaging to await disposition, be it in the operating theater, in the intensive care unit, or in the ward.

Three-dimensional resuscitation is a concept that has been developed in the deployed military hospital and in select civilian trauma centers. In this scenario, advanced notification from the field or en route care platform allows the team leader to identify the small number of patients who will benefit from direct transfer from the ambulance or helicopter to the operating theater. In the wartime setting, these patients are often injured from explosive events, have single or multiple amputations or have torso injuries and are in pending cardiovascular collapses from hypovolemia. Three-dimensional resuscitation begins with the trauma team assembling in the operating theater. Universal donor red cells (O negative) and plasma (AB positive) are primed for administration to the patient using a rapid transfusion device with or without a warming mechanism. Blood-component replacement therapy is guided by thromboelastography (TEG) undertaken in the operating theater. Complications of massive transfusion (hyperkalemia and hypocalcemia) are anticipated, proactively monitored with a handheld analyzer, and aggressively corrected. Resuscitation starts as soon as the patient arrives and continues through induction of anesthesia and performance of procedures to augment resuscitation (i.e., resuscitative aortic occlusion) and surgical hemostasis. This approach combines ED resuscitation with imaging, surgery, and early intensive care in one location to address vascular disruption, hemorrhage, shock, and coagulopathy. The configuration of the British field hospital in Afghanistan, where a critical patient may turn left into the main resuscitation bay or right into the adjacent operating theater, has led to this process being referred to as “right turn resuscitation . ”

Preparation

It is an adage that “prior planning and preparation prevents poor performance.” A trauma team that has taken time to prepare will defuse the anxiety during a complex resuscitation and will reduce the direct management needed by the team leader. Preparation includes assembling the trauma team, donning protective equipment, assigning roles, drawing up medications, anticipating necessary procedures, and smoothing the transition to the next stage of treatment. A list of common pitfalls within preparation—and their consequences—is provided in Box 7-1 .

There is a difference of opinion as to when the trauma team should be notified before patient arrival. Activation criteria are generally based on mechanism (e.g., ejection from vehicle), anatomy of injury (e.g., penetrating torso trauma), and physiological derangement (e.g., tachypnea, tachycardia, hypotension). Local variations to criteria may need to be developed taking into account unique patterns of severe injury prone to be seen at a given medical facility (e.g., “rolled over by horse” for a hospital close to a racetrack or equestrian event). Team members may prefer to respond at the last minute to minimize time waiting for the patient. However, time spent in preparation is rarely wasted. In the author’s experience, if a significant injury is suspected, the trauma team should be notified before or at the time the ambulance (land, air) departs the point of injury. Group messages that detail injuries and/or time of arrival allow team members to make a judgment on their speed of response. However, too much speculation on severity of injury or a casual response by members may undermine the team leader’s effective assignment of duties and his or her ability to establish a good team dynamic (e.g., until the anesthetist arrives, someone else must be assigned to manage the airway).

The first action for trauma team members is to don personal protective equipment (PPE). Ideally this should be done at the door to the resuscitation room before entering. Minimal standards are gloves, a lead gown, and a plastic apron; and eye protection is desirable. Tabards that identify the functional role of team members may be especially helpful in centers where team composition regularly changes. These cards, posters, or vests can also be color coded (e.g., red for the team leader).

The trauma team leader should assign roles according to the competencies of the members. If roles are not assigned, there will be predictable duplication of effort (e.g., multiple providers defaulting to attempt to insert an intravenous cannula). Polytrauma patients with vascular trauma in whom the full diagnosis has yet to be made are the “sickest” patients in the hospital at the time of arrival. In these cases it is logical for the most experienced clinician on duty to play a primary role. The UK military model is that consultants in every discipline (emergency medicine, anesthesia, surgery, orthopedics, and radiology) will undertake the relevant assessment and intervention to their specialty. Although such a comprehensive initial assessment has proven useful in the deployed setting, it may rarely be possible in most civilian practices. Nevertheless, even with a less-experienced team, the anesthetist should be assigned to the airway, an emergency physician or general surgeon to the primary survey, and an orthopedic surgeon to the secondary survey of the limbs and pelvis.

To prevent having to repeat the prehospital or history multiple times to team members who arrive at different stages, it is advisable to annotate the injury scenario on an information board for all to see. One format that has been useful to the author is the abbreviation MIST, which stands for mechanism, injuries (found and suspected), signs (physiological), treatment. With multiple casualties, patients can be preassigned treatment bays; and the limited manpower resources can then be distributed based on the MIST categories.

It is important to note that some medications are required or can at least be anticipated for nearly all major resuscitations following vascular trauma with shock. A patient with an isolated head injury and coma will require a computed tomography (CT) scan of the brain, and an anesthetic will be needed to secure the airway before the procedure. When severity of injury is communicated from the point of injury or the en route care platform (i.e., 3-D resuscitation), these commonly used medications can be drawn up and prepared in advance. This not only speeds the time to anesthesia, CT, and diagnosis, but it also allows the anesthetist to focus on managing the airway, rather than being potentially distracted by having to draw up or prepare medications once the patient arrives. The same reasoning applies to analgesia and intravenous fluids or blood component, where nursing time can be saved by preplanning during the so called 3-D resuscitation time.

Equipment requirements can also be anticipated. For example, if the team is expecting a patient with concomitant facial burns, equipment for intubation can be prepared including a smaller than normal, uncut tube with a bougie in anticipation of airway edema. In this scenario, equipment for a surgical airway (i.e., cricothyroidotomy) should be readied; and the surgeon to perform this procedure, if it is deemed necessary, should be identified. Smoothing transition following immediate resuscitation can also begin in the preparation phase. When a patient will need CT imaging, the radiologist can be warned and routine use of the scanner adjusted to ensure its availability. Similarly, when emergency surgery is likely (e.g., gunshot wound to the abdomen or severely mangled extremity) advance notification of the operating theater should occur.