Makindo Medical Notes

Related Subjects: |Acute Haemorrhage |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma

Main Principles

• 🚑 Rapid transfer to a specialist trauma centre whenever possible.
• 🩸 Early coagulation monitoring & support → goal-directed resuscitation.
• 🔪 Damage-control surgery is prioritised in unstable patients; definitive surgery only when physiology allows.

Haemorrhage Control

• 🖐️ Direct pressure with simple dressings = first-line for most civilian bleeding.
• 🩺 Foley catheter tamponade – can be used for penetrating junctional injuries (neck, axilla, groin).
• 🦵 Tourniquet – if direct pressure fails in life-threatening limb haemorrhage.
• 🦴 Pelvic binder – apply early in suspected unstable pelvic fracture (esp. prehospital).
• 💊 Tranexamic Acid (TXA): give ASAP in major trauma with suspected bleeding; avoid >3h post-injury unless clear hyperfibrinolysis.

🌟 Key Exam Pearl: TXA within 3 hours of injury reduces mortality (CRASH-2 trial).

Tourniquets

• 💉 Indicated for uncontrolled arterial bleeding in mangled extremity injuries, amputations, penetrating/blast wounds.
• 🪖 Evidence mainly from military combat trauma; safe and effective.
• 🚫 Not for closed injuries or minor bleeding.
• ⏱️ Limit to < 2 hours ideally. Rare complications (nerve palsy, ischaemia) if prolonged.
• ✅ Survival of extremity reported even after 6h in combat series.

Pelvic Ring Binders

• 💀 Unstable pelvic fractures = highly lethal; cause massive retroperitoneal bleeding.
• 🦴 Early application of pelvic binder reduces pelvic volume & bleeding → used increasingly prehospital.
• ⚠️ Difficult to detect clinically (esp. unconscious patients) → maintain high suspicion.
• 📌 Further management:
  • External fixation
  • Retroperitoneal packing
  • Angioembolisation
  • Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA)
• Multidisciplinary team (trauma, ortho, interventional radiology) essential.

Anticoagulant Reversal

• ⏱️ Rapid reversal in actively bleeding trauma patients.
• 💉 Prothrombin Complex Concentrate (PCC) = first line for VKA reversal. Plasma is NOT recommended.
• ⚠️ Do NOT reverse if no bleeding present – seek haematology advice.
• 📊 Activate major haemorrhage protocol based on physiology & resuscitation response, not a static “risk score.”
• 💉 If IV access fails → intraosseous access is recommended prehospital.

Volume Resuscitation

• 📉 Restrictive strategy until bleeding controlled (avoid dislodging clots/dilutional coagulopathy).
• 🚑 Prehospital: titrate to palpable central pulse (carotid/femoral).
• 🏥 Hospital: move rapidly to definitive haemorrhage control; titrate to maintain central circulation.
• 🧠 With TBI:
  • If haemorrhage dominates → restrictive fluids.
  • If TBI dominates → maintain cerebral perfusion pressure (less restrictive).
• 💉 Crystalloids: avoid if blood available; use only as a bridge prehospital.
• 🩸 Balanced transfusion: Adults 1:1 RBC:Plasma; Children weight-based 1:1.

Damage Control Surgery

• 🚨 Unstable + non-responsive → damage control surgery (control bleeding/contamination, temporary closure).
• 📈 Unstable but responding → consider definitive surgery.
• 🟢 Stable physiology → proceed with definitive repair.

📝 Summary: - Stop bleeding early (pressure, tourniquet, binder, packing). - Reverse anticoagulants if bleeding. - Restrictive fluids until control achieved. - Early TXA (within 3h). - Escalate to damage-control surgery if instability persists.

References

• European Guidelines on Bleeding in Trauma
• NICE NG39: Major Trauma