Fecher Alison, Stimpson Anthony, Ferrigno Lisa, Pohlman Timothy H
Division of Acute Care Surgery, Lutheran Hospital of Indiana, Fort Wayne, IN 46804, USA.
Department of Surgery, UCHealth, University of Colorado-Denver, Aurora, CO 80045, USA.
J Clin Med. 2021 Oct 19;10(20):4793. doi: 10.3390/jcm10204793.
The recognition and management of life-threatening hemorrhage in the polytrauma patient poses several challenges to prehospital rescue personnel and hospital providers. First, identification of acute blood loss and the magnitude of lost volume after torso injury may not be readily apparent in the field. Because of the expression of highly effective physiological mechanisms that compensate for a sudden decrease in circulatory volume, a polytrauma patient with a significant blood loss may appear normal during examination by first responders. Consequently, for every polytrauma victim with a significant mechanism of injury we assume substantial blood loss has occurred and life-threatening hemorrhage is progressing until we can prove the contrary. Second, a decision to begin damage control resuscitation (DCR), a costly, highly complex, and potentially dangerous intervention must often be reached with little time and without sufficient clinical information about the intended recipient. Whether to begin DCR in the prehospital phase remains controversial. Furthermore, DCR executed imperfectly has the potential to worsen serious derangements including acidosis, coagulopathy, and profound homeostatic imbalances that DCR is designed to correct. Additionally, transfusion of large amounts of homologous blood during DCR potentially disrupts immune and inflammatory systems, which may induce severe systemic autoinflammatory disease in the aftermath of DCR. Third, controversy remains over the composition of components that are transfused during DCR. For practical reasons, unmatched liquid plasma or freeze-dried plasma is transfused now more commonly than ABO-matched fresh frozen plasma. Low-titer type O whole blood may prove safer than red cell components, although maintaining an inventory of whole blood for possible massive transfusion during DCR creates significant challenges for blood banks. Lastly, as the primary principle of management of life-threatening hemorrhage is surgical or angiographic control of bleeding, DCR must not eclipse these definitive interventions.
对多发伤患者危及生命的出血进行识别和处理，给院前急救人员和医院医护人员带来了诸多挑战。首先，在现场可能无法轻易识别躯干损伤后的急性失血情况以及失血量。由于存在高效的生理机制来代偿循环血量的突然减少，一名大量失血的多发伤患者在急救人员检查时可能看起来正常。因此，对于每一名具有明显致伤机制的多发伤受害者，在我们能够证明相反情况之前，我们都假定已经发生了大量失血且危及生命的出血正在进展。其次，决定开始实施损伤控制复苏（DCR），这是一种成本高昂、高度复杂且具有潜在危险性的干预措施，往往必须在短时间内做出，且没有关于预期接受者的足够临床信息。是否在院前阶段开始DCR仍存在争议。此外，如果DCR执行得不完善，有可能使包括酸中毒、凝血功能障碍和严重内环境失衡等严重紊乱情况恶化，而DCR正是旨在纠正这些情况。另外，在DCR过程中输注大量同源血有可能扰乱免疫和炎症系统，这可能在DCR之后诱发严重的全身性自身炎症性疾病。第三，关于DCR期间输注成分的组成仍存在争议。出于实际原因，目前输注不匹配的液体血浆或冻干血浆比输注ABO匹配的新鲜冰冻血浆更为常见。低滴度O型全血可能比红细胞成分更安全，尽管在DCR期间为可能的大量输血维持全血库存给血库带来了重大挑战。最后，由于处理危及生命出血的主要原则是通过手术或血管造影控制出血，DCR绝不能掩盖这些确定性干预措施。
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