Diagnostic et prise en charge de la coagulopathie post-traumatique

Tactical damage control resuscitation in austere military environments

BACKGROUND

Despite the early uses of tourniquets and haemostatic dressings, blood loss still accounts for the vast majority of preventable deaths on the battlefield. Over the last few years, progress has been made in the management of such injuries, especially with the use of damage control resuscitation concepts. The early application of these procedures, on the field, may constitute the best opportunity to improve survival from combat injury during remote operations.

DATA SOURCES

Currently available literature relating to trauma-induced coagulopathy treatment and far-forward transfusion was identified by searches of electronic databases. The level of evidence and methodology of the research were reviewed for each article. The appropriateness for field utilisation of each medication was then discussed to take into account the characteristics of remote military operations.

CONCLUSIONS

In tactical situations, in association with haemostatic procedures (tourniquet, suture, etc), tranexamic acid should be the first medication used according to the current guidelines. The use of fibrinogen concentrate should also be considered for patients in haemorrhagic shock, especially if point-of-care (POC) testing of haemostasis or shock severity is available. If POC evaluation is not available, it seems reasonable to still administer this treatment after clinical assessment, particularly if the evacuation is delayed. In this situation, lyophilised plasma may also be given as a resuscitation fluid while respecting permissive hypotension. Whole blood transfusion in the field deserves special attention. In addition to the aforementioned treatments, if the field care is prolonged, whole blood transfusion must be considered if it does not delay the evacuation.

Haemorrhagic shock, therapeutic management

The management of a patient in post-traumatic haemorrhagic shock will meet different logics that will apply from the prehospital setting. This implies that the patient has beneficiated from a "Play and Run" prehospital strategy and was sent to a centre adapted to his clinical condition capable of treating all haemorrhagic lesions. The therapeutic goals will be to control the bleeding by early use of tourniquet, pelvic girdle, haemostatic dressing, and after admission to the hospital, the implementation of surgical and/or radiological techniques, but also to address all the factors that will exacerbate bleeding. These factors include hypothermia, acidosis and coagulopathy. The treatment of these contributing factors will be associated to concepts of low-volume resuscitation and permissive hypotension into a strategy called "Damage Control Resuscitation". Thus, the objective in situation of haemorrhagic shock will be to not exceed a systolic blood pressure of 90 mmHg (in the absence of severe head trauma) until haemostasis is achieved.