Fluid Resuscitation for Trauma Patients: Crystalloids Versus Colloids

Controversy regarding the role of colloids in the resuscitation of trauma patients has persisted for the past century without a clear resolution. Recently, the early treatment goals of traumatic hypovolemic shock have changed with an emphasis on minimal intravenous fluid administration and the avoidance of over-resuscitation. While some clinicians see a role for colloids in this model, others have become wary as evidence mounts against the efficacy and safety of hydroxyethyl starch and human albumin in critically ill patients. We reviewed the history and fundamentals of the crystalloid versus colloid debate and explored the relevant findings from the prominent non-trauma literature with attention to their applicability in the trauma population. Critical appraisal of the trauma-specific colloid literature is offered with a focus on study design and practical utility. Finally, we offer recommendations about the rational selection of fluids for clinicians who treat these challenging patients

Management of Respiratory Distress Syndrome due to COVID-19 infection

The management of Acute Respiratory Distress Syndrome (ARDS) secondary to the novel Coronavirus Disease 2019 (COVID-19) proves to be challenging and controversial. Multiple studies have suggested the likelihood of an atypical pathophysiology to explain the spectrum of pulmonary and systemic manifestations caused by the virus. The principal paradox of COVID-19 pneumonia is the presence of severe hypoxemia with preserved pulmonary mechanics. Data derived from the experience of multiple centers around the world have demonstrated that initial clinical efforts should be focused into avoid intubation and mechanical ventilation in hypoxemic COVID-19 patients. On the other hand, COVID-19 patients progressing or presenting into frank ARDS with typical decreased pulmonary compliance, represents another clinical enigma to many clinicians, since routine therapeutic interventions for ARDS are still a subject of debate

Resuscitation in a Multiple Casualty Event

A major weakness in the emergency medical response to multiple casualty events continues to be the resuscitation component, which should consist of the systematic application of basic, advanced, and prolonged life support and definitive care within 24 hours. There have been major advances in emergency medical care over the last decade, including the feasibility of point-of-care ultrasound to aid in rapid assessment of injuries in the field, damage control resuscitation, and resuscitative surgery protocols, delivered by small trauma/resuscitation teams equipped with regional anesthesia capability for rapid deployment. Widespread adoption of these best practices may improve the delivery of resuscitative care in future multiple casualty events

Pro-Con Debate: Viscoelastic Hemostatic Assays Should Replace Fixed Ratio Massive Transfusion Protocols in Trauma

Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the "1:1:1" combination of 1 units of red cells, 1 unit of plasma, and 1 donor's worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient's hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma

Changing Paradigms in Hemostatic Resuscitation: Timing, Extent, Economic Impact, and the Role of Factor Concentrates

Damage-controlled hemostatic resuscitation has become a standard of care for critically injured patients. Recently completed PROPRR trial demonstrated hemostatic benefits of 1:1:1 Platelets:FFP:RBC transfusion approach, although overall mortality did not decrease. Improved logistics of resuscitation (decreased crystalloid administration), optimization of blood product delivery with adoption of massive transfusion protocols (short time to first unit of plasma transfused), and better early post-MTP management are the factors that contributed to lower than expected mortality in this study. Liquid plasma and pre-thawed Type A fresh frozen plasma (FFP) are safe alternatives to universal donor Type AB FFP and have been adopted by few trauma centers in North America due to shortage of AB FFP supply

Correction of Severe Coagulopathy and Hyperfibrinolysis by Tranexamic Acid and Recombinant Factor VIIa in a Cirrhotic Patient After Trauma: A Case Report

Coagulopathy induced by trauma or cirrhosis is a well-recognized entity. Viscoelastic testing has been used in either condition for goal-directed transfusion and detection of fibrinolysis since conventional coagulation tests do not correlate with clinical risk of bleeding. Hemostatic resuscitation may not be adequate for a trauma patient with liver disease due to complex alterations in coagulation systems and occasionally require adjuvant therapy. We report a case of trauma-induced coagulopathy presenting as severe hyperfibrinolysis in a cirrhotic patient who was refractory to hemostatic resuscitation but was rapidly corrected by the administration of tranexamic acid and recombinant Factor VIIa