Edited by: Dr Faran Bokhari
Bleeding is a leading cause of death in trauma. While tourniquets have resulted in substantial improvement in survival in injured patients such targeted and effective treatments are rare in torso hemorrhage.
Penetrating and blunt trauma can cause internal bleeding in the chest, abdomen or pelvis. This bleeding can manifest itself as decreased pulse pressure, altered shock index or frank hypotension. Resuscitation can be performed with crystalloid, packed RBCs and FFP or even whole blood. There is much controversy as to what goals should be used for resuscitation. Hypotensive resuscitation is advocated by some. Target parameters are subjective at best. There is increasing evidence that balanced blood product ratios (FFP: PRBC 1:1) improve survival. There is also evidence that survival is improved by earlier blood product administration. The limits of improvement of this approach are not well described.
In the emergency department diagnosis and treatment of hemorrhagic shock is variable. Emergent diagnosis might involve diagnostic peritoneal lavage, ultrasound or plain films. The efficacy of these modalities can be different for different injuries. While e-FAST (extended focused abdominal sonography for trauma) might reveal pericardial, pleural or intra-peritoneal bleeding, retroperitoneal hemorrhage might not be obvious. Surgical or radiological intervention might need to be rendered as soon as possible. MAST trousers are no longer in vogue. A reduced time to intervention might reduce mortality. Bridges such as REBOA (Resuscitative endovascular balloon occlusion of the aorta) are increasingly used. The exact indications for application of the REBOA are still being defined as are the specific advantages over emergency department thoracotomy.
Pelvic fracture management involves decreasing pelvic volume with external binders and possible embolization by interventional radiology (IR). However, it is unclear if either the timing of IR or its exact indications are well defined. Only 10-20% of pelvic fractures are amenable to IR since the majority of pelvic fracture bleeding is venous. The merits of extra-peritoneal pelvic packing versus IR, a priori, in all comers are not well known.
The sequalae of massive hemorrhagic shock can include multiorgan system injury or failure. These physiologic dysfunctions while extensively studied are difficult to manage with any degree of satisfactory success.
In this thematic series, we would like to better understand the Severe Torso Trauma.
This series was published in Military Medical Research.