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Review
. 2023 May 24;31(1):25.
doi: 10.1186/s13049-023-01088-8.

Traumatic hemorrhage and chain of survival

Rana K Latif  1   2   3 , Sean P Clifford  4 , Jeffery A Baker  5 , Rainer Lenhardt  4 , Mohammad Z Haq  4 , Jiapeng Huang  4   6   7   8   9 , Ian Farah  4 , Jerrad R Businger  4
Affiliations
Review

Traumatic hemorrhage and chain of survival

Rana K Latif et al. Scand J Trauma Resusc Emerg Med. .

Abstract

Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.

Keywords: Chain of survival algorithm in trauma; Damage control resuscitation; Damage control surgery; Diagnostic imaging in trauma; Traumatic hemorrhage.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Pathophysiology of traumatic hemorrhagic shock. a Traumatic hemorrhage five locations. b Traumatic hemorrhagic response. (1) Genomic response. Up-regulated anti-inflammatory genes with rapid recovery. Up-regulated pro- inflammatory genes leads to complications and death. (2) Cellular response. Anerobic metabolism with damage to mitochondria, smooth endoplasmic reticulum (SER) and rough endoplasmic reticulum (RER), leading to cellular homeostasis failure. (3) Tissue response. Local hemostatic plug formation with conversion of fibrinogen to fibrin. Distant coagulopathy with hyperfibrinolysis and diffuse coagulopathy. (4) Organ response. Moderate hemorrhage with end-organ damage and Exsanguination leading to death. aPC activated protein C, CARS compensatory anti-inflammatory response syndrome, DAMPs damage-associated molecular patterns, DNA deoxyribonucleic acid, Pi inorganic phosphate, C3H6O3 lactic acid, MOF multi organ failure, O2–, OH–, oxygen radicals, RE respiratory enzymes, SIRS systemic inflammatory response syndrome, tPA tissue plasminogen activator, ↑ increased
Fig. 2
Fig. 2
a Chest X-ray AP view. Right sided hemothorax, right lateral pneumothorax and subcutaneous emphysema. b Pelvic AP view. Widening of right sacroiliac joint with right sacral fracture and vertical shift (potential vascular injury), bilateral superior inferior pubic rami fracture (risk for bladder injury), left acetabular fracture. c Subxiphoid view of the heart (2D). Large pericardial effusion causing tamponade. d Right thoracic view at the diaphragm with a right hemothorax. Thoracic spine visualized above the diaphragm (spine sign). Normally, the thoracic spine is obscured by air within the lung. D diaphragm, HT hemothorax, L liver, LV left ventricle, PE pericardial effusion, PT pneumothorax, RV right ventricle, SE subcutaneous emphysema, SI sacroiliac joint, SS spine sign, T thrombus, TS thoracic spine
Fig. 3
Fig. 3
a Right upper quadrant view (RUQV) of the abdomen. Anechoic hemoperitoneum in the hepatorenal space. b Left upper quadrant view (LUQV) of the abdomen. Anechoic hemoperitoneum in the splenorenal space. c Pelvic sagittal view. Anechoic hemoperitoneum cephalad and posterior to the bladder. d Pelvic transverse view. Anechoic hemoperitoneum posterior to the bladder. B bladder, HP hemoperitoneum, L liver, LK left kidney, RL right kidney, S spleen
Fig. 4
Fig. 4
a TTE sagittal view of IVC long axis during inspiration; b IVC during expiration. Collapses > 50% with respiration provide insight into the fluid status of an adult trauma patient. c TEE transgastric short axis view during diastole; d systole. Severe left ventricular hypovolemia and papillary muscle kissing sign during systole. HP hepatic vein, IVC inferior vena cava, L liver, LV left ventricle, RA right atrium, RV right ventricle
Fig. 5
Fig. 5
Traumatic hemorrhage and chain of survival. ATLS, Advanced Trauma Life Support; CXR, chest X-ray; CT, computed tomography; FAST, Focused Assessment with Sonography in Trauma; MTP, Massive Transfusion Protocol; 1:1:1, equal amounts of packed red cells, fresh frozen plasma, and platelets
See this image and copyright information in PMC

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