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EREVIEW ARTICLE
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MILITARY CARE
Forward critical care resuscitation is an important component of the trauma care continuum in the military. Tactical
Combat Casualty Care beginning at the point of injury helps
mitigate blood loss, treats pain, and provides for immediate
antibiotic therapy.5 In current military operations, a variety of medical echelons initiate damage control resuscitation en route to the combat trauma center, where surgical
and radiologic intervention is undertaken in parallel with
continued resuscitation. Critical Care Air Transport Teams
in the US Air Force use an intensivist, nurse, and respiratory therapist, together with their equipment, to turn large
cargo aircraft into an airborne critical care unit. They are
able to transport 6 stabilized, but not necessarily stable,
patients (up to 3 of whom can be ventilated) to definitive
surgical care outside of the war zone.6,7 The British Medical
Emergency Response Team uses a physician, nurse, and
2 paramedics to transport patients via helicopter to the
combat trauma center. Their p
hysician-
based model has
demonstrated improved survival in traumatic brain injury
(attributable to emergency anesthesia and ventilation) and
improved survival in thoracic injury (attributable to emergency anesthesia, ventilation, and chest tube drainage).8
Current discussion in the US military addresses the potential need to develop a rotary wing critical care element to
bridge the gap in the continuum of care from wounding to
advanced surgical intervention.9,10
DAMAGE CONTROL
HYPOTENSIVE RESUSCITATION
Key concepts in trauma care are source control of hemorrhage and resuscitation with blood products. A careful
evaluation of the fluids and blood products needed to resuscitate these patients is an important component of the anesthetic contribution to DCR.22,23
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Better understanding of transfusion practices, and a more
refined definition of massive transfusion in the trauma
patient, has led to improved resuscitation with blood products.24 In addition, appreciation for trauma-induced coagulopathy has prompted early empiric treatment, rather than
a more reactive response to documented coagulation
abnormalities. Many institutions have revised their massive transfusion protocols to include the use of 1:1 ratios
of red blood cells (RBCs) to fresh frozen plasma (FFP)
transfusion.25 Military studies on the ratio of RBCs to FFP
reported improved survival in the wounded combatant.26
In one study, the FFP to RBC ratio was evaluated in 246
battle-
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Ideally, a w
ell-
controlled randomized trial could
answer the question of survivor bias more conclusively.
The Pragmatic Randomized Optimum Platelet and Plasma
Ratio (PROPPR) trial is an ongoing multicenter, prospective, randomized study that will evaluate different blood
product ratios to be administered to trauma patients in
need of >10 U of PRBCs in the first 24 hours. This will offer
an opportunity to prospectively evaluate the ideal ratio of
blood products for use in trauma.
PHARMACOLOGIC ADJUNCTS
TRANEXAMIC ACID
Tranexamic acid is a synthetic lysine derivative that competitively inhibits lysine binding sites on plasminogen,
blocking the conversion of plasminogen to plasmin. This
inhibits the proteolytic action of plasmin on fibrin clot and
platelet receptors, and serves as an effective antifibrinolytic.
In the CRASH-2 trial, 20,211 trauma patients were randomized to receive either tranexamic acid (1 g initial loading
followed by 1 g over 8 hours) or placebo.33 This multicenter,
prospective trial demonstrated significant reductions in
all-cause mortality, and in deaths due to bleeding, without
increasing vascular occlusive events in the tranexamic acid
group, compared with the placebo group. Further analysis
by the investigators revealed that the benefit was only seen
when tranexamic acid was administered within 3 hours
of injury and that increase in mortality occurred when the
drug was given after this period. Surprisingly, however,
there was no statistical difference in blood transfusion
between the tranexamic acid and placebo groups. Exactly
how tranexamic acid reduced the risk of death in bleeding
patients remains unanswered.
A subgroup analysis of the CRASH-2 trial included 270
adult trauma patients at risk for extracranial bleeding who
also had a traumatic brain injury.34 These patients received
tranexamic acid (1 g bolus followed by infusion, as in the
CRASH-2 trial) or placebo. Intracranial hemorrhage growth
as measured by computed tomography was examined. Mean
total hemorrhage growth between the tranexamic acid arm
and placebo was no different. Likewise, new focal ischemic
lesions were not significantly different in the 2 groups. The
authors speculated that a decrease in the size of the intracranial hemorrhage would decrease local pressure on arteries and, therefore, decrease the risk of ischemia. This effect,
however, was not demonstrated here. A f ollow-up study, the
CRASH-3 trial, will examine head injury more closely.
The Military Application of Tranexamic Acid in Trauma
and Emergency Resuscitation (MATTERs) study35 evaluated the use of tranexamic acid in hemorrhagic shock after
combat injury in 896 consecutive trauma admissions, 293 of
whom received the drug. Unadjusted mortality was lower
VASOPRESSIN
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OTHER PHARMACOLOGIC ADJUNCTS
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POSTRESUSCITATIVE CARE
CONCLUSION
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