Uncontrolled bleeding in patients with major abdominal trauma


COD: 04_2013_365-370 Categorie: ,

Franco Stagnitti

Ann. Ital. Chir., 2013 84: 365-369

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Haemodynamically unstability after severe abdominal injuries requires a new therapeutic strategy. European guidelines recommend: reduced time, non-invasive investigations, avoid massive volemic replacement before surgery. The primary aim of Damage Control Resuscitation protocol is to prevent the lethal triad: hypothermia, acidosis and coagulopathy. The treatment includes contemporary: permissive hypotension, haemostatic resuscitation, and Damage Control Surgery (DCS). Systolic pressure below the physiological limits maximize the benefits of resuscitation and haemostasis, decreasing vessel clots expulsion. Haemostatic resuscitation uses blood components and substitutes, to allow volemic replacement and to avoid traumainduced coagulopathy (25% – 30% of complex trauma). The use of PRBCs and plasma 1 to 1 is an independent survival predictor in patients undergoing DCS. Military haemostatic resuscitation protocol suggests massive transfusion using 10 or more PRBCs during 24 or 6 hours if 3 or more triggers are present: pressure > 90, hemoglobin > 11 g, temperature < 35.5°C, INR > 1.5, base deficit 6. Joint Theater Trauma Registry demonstrated if we maintain PAS around 70-80 mmHg, using plateled, plasma PRBCs (1-1-1) and limiting crystalloids (250 cc), haemocomponents utilization decrease, mortality is reduced 65 % vs 19 % and Abdominal Compartment Syndrome incidence is limited. When bleeding persists despite 10 PRBCs are infused, rFVIIa is recommended and Tranexanic Acid is essential in the drug list. Contemporary DCS performs packing for bleeding solve, intestinal diversion to avoid contamination and temporary wall closure to limit abdominal tension.