Hemorrhage and Acute Traumatic Coagulopathy

Study Notes

Hemorrhage is a life-threatening condition that must be identified and managed promptly.
It leads to hypovolemic shock and can result in death or multiple organ failure.
Treating hemorrhage focuses on stopping the bleeding, not solely on fluid resuscitation or blood transfusions.
Aggressive resuscitation in the presence of ongoing hemorrhage can worsen the condition, leading to coagulopathy, acidosis, hypothermia, and ultimately death.

ATC develops within minutes of injury in up to 25% of trauma patients.
It is associated with a 4-fold increase in mortality.
It is likely present whenever there is a combination of shock and tissue trauma.

### Pathophysiology of Hemorrhage

Hemorrhage leads to hypovolemic shock, which triggers ATC.
Ongoing bleeding with fluid and red blood cell resuscitation dilutes clotting factors, worsening the coagulopathy.
Acidosis, a consequence of hypoperfusion, further impairs coagulation function, leading to a vicious cycle.
Reduced tissue perfusion, particularly in muscles, leads to hypothermia, further impairing coagulation and worsening the cycle.

### Types of Hemorrhage

Hemorrhage can be revealed (external, visible bleeding) or concealed (internal bleeding within body cavities).
Primary hemorrhage occurs immediately due to injury or surgery.
Reactionary hemorrhage occurs within 24 hours and is usually due to dislodged clots or technical failures.
Secondary hemorrhage occurs 7-14 days after injury and is often caused by infection, pressure necrosis, or malignancy.
Surgical hemorrhage is directly related to injury and can be controlled surgically.
Non-surgical hemorrhage is a general bleeding from raw surfaces caused by coagulopathy and cannot be stopped surgically.

Adults have approximately 5 liters of blood.
Estimating blood loss is difficult and often underestimates the actual amount.
Hemoglobin levels are not reliable indicators of blood loss, as they represent a concentration rather than a total volume.
Treatment is based on the severity of hypovolemic shock, vital signs, preload assessment, base deficit, and response to fluid therapy.

### Management of Hemorrhage

Identify the source of bleeding.
Apply direct pressure to external hemorrhage.
Assess and control airway and breathing if necessary.
Establish large-bore intravenous access and obtain blood for cross-matching.
Immediately locate and control bleeding.
Avoid unnecessary investigations or procedures before hemorrhage control.
Correct coagulopathy with blood component therapy.
Limit surgical intervention to the minimum necessary to stop bleeding.
Post-hemorrhage control, aggressively resuscitate, warm the patient, and correct coagulopathy.

### Damage Control Surgery (DCS)

DCS aims to arrest hemorrhage, control sepsis, and protect against further injury.
It involves immediate hemorrhage control, minimal surgery, and delayed definitive repair.

### Damage Control Resuscitation (DCR)

DCR integrates DCS with resuscitation strategies to manage trauma patients with active hemorrhage, focusing on:
- Anticipating and treating ATC.
- Permissive hypotension until bleeding is controlled.
- Limiting crystalloid and colloid infusion to avoid dilution of clotting factors.
- Conducting DCS to control bleeding and preserve physiology.