An introduction to the initial hospital management of acute trauma

Circulation and haemorrhage control

Two intravenous cannulae (grey, 16g or bigger) should be inserted, and basic observations taken (blood pressure, heart rate, O₂ saturation) on a regular basis. Tachycardia and/or hypotension after traumatic injury is assumed to be due to significant (>30% blood volume) blood loss until proven otherwise. Stopping haemorrhage with rapid haemostatic techniques (eg compression, bandage, pelvic splint, fracture reduction, interventional angiography or laparotomy) is the first priority in the treatment of traumatic haemorrhagic shock, with concomitant fluid resuscitation (fluid and blood) to maintain perfusion and organ function.

One approach to in-hospital resuscitation for the treatment of trauma patients with haemorrhagic shock is the rapid infusion of two litres of crystalloid, However many experts advocate giving less and observing the response ie halt bleeding while maintaining adequate tissue perfusion: this is a controversial area.

This may be followed by blood transfusion with blood (uncrossmatched blood ie O-negative, ABO type specific or fully crossmatched depending on urgency and availability) if there is evidence of ongoing hypovolaemia or anaemia. Fresh frozen plasma and cryoprecipitate should be considered early in massive haemorrhage.

The resuscitation endpoints (how to tell if you have given enough) that have been evaluated include restoration of blood pressure, heart rate and urine output, capillary refill, lactate, base deficit, mixed venous oxygen saturation, and ventricular end-diastolic volume. Remember, patients can compensate for hypovolaemia (by vasoconstricting) and so delay the appearance of tachycardia and hypotension. Bleeding can occur externally or be from the thoracic, abdominal or pelvic cavities, long bones or spine. Diagnosis can be aided by ultrasound (eg ‘FAST’ scan: Focused Assessment with Sonography for Trauma), CT, X-ray, angiography, diagnostic peritoneal lavage and blood tests (FBC, U + E, blood gasses).