Update on trauma

Background Vehicular injury causes five million deaths a year. Vehicles, interpersonal violence, falls, occupational physical injury, injuries in the home and recreational injury all contribute to make physical injury the leading cause of the loss of years of productive life worldwide. As a result, injury prevention is a societal goal in all developed, most developing, and many poor countries. Uncontrolled hemorrhage is the second leading cause of death from physical injury and its primary prevention through accident prevention, secondary prevention through trauma care systems and surgical hemorrhage control, and secondary and tertiary prevention through appropriate transfusion all contribute to saving lives and returning individuals to productive activities. These activities need to cover the almost a billion people who suffer significant physical injury each year. Aims Provide an update on blood use in trauma. Methods Literature from the last 10 years was reviewed for advances in the understanding of injury-related bleeding, surgical hemorrhage control methods, drugs, and devices, and changing patterns of blood use. Selected examples are discussed. Results Recognition of the pH-dependence of the plasma coagulation system activity and the temperature limits on platelet activation through von Willebrand’s factor traction on glycoprotein Ib/IX provide a clear mechanistic pathway from acidosis and hypothermia to coagulopathy and excess deaths following injury. The description of the acute coagulopathy of trauma and shock (ACoTS), an acute form of hemorrhagic DIC associated with severe injury, shock, and activation of the protein C system, has also been a major advance. The development of prehospital hemorrhage control systems such as better tourniquets, and active hemorrhage control bandages, systems for keeping patients warm, and efforts in monitoring to reduce the prehospital use of crystalloid and colloid fluids have all been noted to improve outcome. Pre-hospital fluid restriction is now known to reduce blood loss, reduce hemodilution, and prevent platelet dysfunction. In the hospital, dedicated trauma systems, advances in imaging with ultrasound, CT, and MRI, and protocols for the rapid stabilization of physiology through surgery, interventional radiology, organ system support, and advanced nursing are improving survival and reducing complications. Hemorrhage control resuscitation, including hypotensive resuscitation to reduce blood loss during a rapid initial assessment and hemostatic resuscitation using relatively more plasma, platelets, and cryoprecipitate early appears to both save lives and reduce total blood use. Evidence supporting hemorrhage control remains Class III, but is increasingly robust. Randomized trials are in preparation. The importance of early initiation of tranexamic acid was demonstrated in the CRASH-II. Once patients are initially stabilized, blood avoidance reduces complications. Moving beyond conventional blood components to resuscitation with coagulation factor concentrates is an area of ongoing research. Using modern prothrombin complex concentrates and fibrinogen concentrates in conjunction with early platelet transfusion allows reconstitution of the extrinsic pathway and has been demonstrated to save lives and reduce blood use. Conclusions Early and balanced use of blood products in severe trauma appears to be saving lives and reducing total blood use. Better and safer tools for hemorrhage control and resuscitation can save more lives.