Hemostatic resuscitation for acute traumatic coagulopathy

Trauma resuscitation paradigms have changed considerably over the last twenty years. Originally, the goal was to normalize a blood pressure as quickly as possible. Large volume crystalloid resuscitation was used to accomplish this. Standard therapy was that any patient with suspected bleeding received a two liter crystalloid bolus as initial therapy. It was often repeated and blood transfusion therapy was used relatively late. Fresh frozen plasma and platelets were also used relatively late, often after patients had received ten units of red cells. Dilutional anemia was relatively common. Patients with large volume blood loss often died from what was termed, "the bloody vicious cycle," of hypothermia, acidosis and coagulopathy. Some of this was almost certainly iatrogenic from our resuscitation strategies [1].The epidemic of urban violence that plagued large American cities in the late 1980's and early 1990's focused trauma surgeons on rethinking how we cared for serious injury. Damage control techniques were described and were incorporated into clinical practice [2]. In addition, use of deliberate hypotension was proven to be an effective strategy in the two randomized prospective trails that have been conducted in humans [3,4]. This is now widely practiced in many trauma centers, particularly in patients under the age of sixty-five years who do not have concomitant brain or spinal cord injuries.Hemostatic resuscitation has also recently become a popular form of transfusion therapy. The concept of giving plasma and platelets early along with red cells in an attempt to closely approximate whole blood makes a lot of sense. In fact, when we reviewed blood usage at the Shock Trauma Center in the year 2000, massively transfused patients ultimately received a unit of plasma for every unit of blood that was transfused [5]. It made a lot of sense that giving FFP earlier would be beneficial. Clinical practice evolved even though there was a paucity of data. The military ado