FlashbackTrauma teams start with two large-bore intravenous lines and infuse 20–30 liters of crystalloid post several hours. Then occurs transfusion of 10 units of red blood cells before ordering any other component. Next, repair injuries using high tidal volume ventilation avoiding any minimally invasive techniques. In a nutshell, high death rates, infrequent utilization of rehabilitation centers by survivors, rare follow-up for traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) patients… |
From then, to now...
There have been significant improvements:
Training
From haphazard training to almost nonexistent simulation centers, we’ve come to an era where prehospital and hospital team training is integrated and commonplace, and simulation centers are widespread. However, uniform translation of these concepts into both military and civilian sectors is unfortunately incomplete.
Stopping bleeding is important
To stop the patient from bleeding sounds so obvious and high priority today, but 20 years ago the emphasis was largely on resuscitation to various cardiac output-based endpoints. We now understand that while surgeons repair the endothelium and restore hemostatic competency, hemorrhage control devices can work on minimizing duration and depth of shock. The integration not only results in decreased hemorrhagic deaths but also reduces edema-related complications in trauma patients.
Transfusion
Exsanguination or excessive, uncontrolled blood loss is the leading cause of potentially preventable death. It occurs quite rapidly (within 6 hours of admission), so understanding the time course of hemorrhagic death is critical towards effective intervention. Optimal resuscitation now starts in the prehospital area with blood products. However, the current paradigm is changing with the TCCC guidelines recommending a move from balanced component transfusion in favor of whole blood.
Neurosurgery and orthopedics
An internal injury in the brain was previously assumed to be fatal. However, the experience gained by medical personnel through treating a large number of such injuries has let aggressive surgical intervention and intensive care to establish. Also, wounds and fractures on the extremities are now easily managed. We’ve learnt that low-pressure and high-volume irrigation combined with serial debridements resulted in the cleanest wounds and that transport with negative pressure devices was safe and greatly facilitated wound care.
What does the future look like?
While it is impossible to predict with certainty, it seems that advances will continue in prehospital resuscitation and hemorrhage control, extending the survivable prehospital time to operative intervention.
What needs to be worked on is decreasing the mortality and morbidity from sepsis, all types of TBI, improvement of pain control and outcomes from PTSD. Successful rehabilitation after injury and reintegration into the workforce must become a focus for every trauma patient. Cellular therapy is likely to become an important early intervention to appropriately modulate the inflammatory system, decreasing multiple organ failures and rebuild or replace damaged organs.
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