Abstracts

Haemostatic and damage control resuscitation: addressing the coagulopathy of exsanguinating trauma

Method: The author deployed to Afghanistan as part of the Australian Defence Force (ADF) contribution to the International Security Assistance Force (ISAF) during the period November 2006 to January 2007, and participated in developing a Massive Transfusion Protocol (MTP) in a North Atlantic Treaty Organisation (NATO) field hospital. Massive Transfusion Protocols (MTPs) are institutionally based approaches to provide for the transfusion and resuscitation requirements of exsanguinating patients. On return to Australia, the author reviewed and compared Australian MTPs with practice in Middle East conflicts.

Results: The MTPs reviewed in Australian civilian centres show substantial variability in the absence of a definitive evidence base or consensus guidelines.

Discussion: Haemostatic resuscitation (HR) is the management of transfusion requirements to prevent and treat coagulopathic bleeding in exsanguinating trauma patients. The trauma patients of concern are those with non-compressible haemorrhage not amenable to control by local measures, including tourniquets and haemostatic dressings. The coagulopathy associated with coagulation factordeplete crystalloid resuscitation of exsanguinating
trauma patients is a component of the lethal triad including acidosis and hypothermia. HR involves combining multiple aspects of haemostatic support as an element in the “bundle” of therapeutic interventions to address this triad, as part of a damage control approach.

HR principles may be used to shape MTPs for ADF use, and have increasingly been applied by multinational forces deployed to the Middle East and other conflicts abroad.

Options for a prototype MTP for ADF use and investigation are presented: triggers; a resuscitation plan with 1:1:1 transfusion of packed red blood cells, plasma and platelets mimicking whole blood; adjuvants including cryoprecipitate, calcium, recombinant activated factor VII, and strategies to reverse acidaemia related changes in the function of coagulation factors; resuscitative end-points; and exit points from the MTP.