The trauma triad of death is made up of hypothermia, coagulopathy, and acidosis. And when it comes to hemorrhagic shock that will occur unless we intervene as quickly as possible. If possible, we want to interrupt the development of the triad be addressing the individual parts as quickly as possible.
Hypothermia occurs in cases of hemorrhagic shock because there is less blood available to maintain body temperature. This drop in temperature effects the chemical process of clotting which can worsen the bleeding. Hypothermia can be minimized in the prehospital setting by covering the patient with blankets as soon as possible while uncovering areas of the body only long enough to complete an exam of the area and control bleeding. Even in the summer months you should consider placing a blanket over your trauma patients. In the cooler months, we should consider the use wrapped hot packs in the groin and axillary regions. The intravenous fluids should also be warmed prior to the administration. In my community during the cooler months we sometimes keep bags of normal saline, we do not carry lactated ringers, on the dashboard to be warmed by the sun or ambulance defroster.
Coagulopathy is the next element in the trauma triad of death. Hypothermia can impair our body’s ability to clot. A preferred treatment would be the administration of whole blood. And while whole blood is being administered in some prehospital settings, it is rare. And a pharmacological intervention is tranexamic acid (TXA).
The data that supports the use of TXA comes from two major studies. The first study was the Military Application of tranexamic acid in Trauma Emergency Resuscitation (MATTERS) study, published in 2012. Which was followed up by the release of the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage (CRASH-2) study, published in 2013.
MATTERS was a retrospective observational study of 893 consecutive admissions of soldiers injured in combat in Southern Afghanistan at an Echelon 3 hospital, which is the equivalent of a level 2 trauma center, 293 patients received TXA, and 603 did not. Researchers monitored patient outcomes at 24 hours, 48 hours, and 30 days. Researchers also monitored postoperative coagulopathy and the rate of thromboembolic complications. When compared to the placebo mortality rate was lower, 17.4% vs. 23.9%. When given within one hour in conjunction w/ blood products mortality was even lower, 14.4% vs. 28.1%. When administered after 3 hours, increase in mortality versus placebo, 4.4% vs. 3.1%. Researchers didn’t find a correlation between death due to bleeding and systolic BP, GCS, or type of injury.
CRASH-2 was a randomized placebo-controlled study and included 274 hospitals in 40 countries. It was determined that when administered in conjunction w/ blood products 30% decrease in mortality. TXA alone demonstrated a 20% decrease in mortality.
The final element of the trauma triad of death is acidosis. As we know, our pH likes to hang out between 7.35 and 7.45. Trauma patients can develop acidosis as cells turn to anaerobic metabolism because of impaired circulation and injured tissue. Acidosis decreases the fibrin and inhibits clotting. We can see a decrease in coagulation by up to 40%. Oxygen therapy can help to clear out some of the acidosis as can A more likely intervention is the administration of IV fluids, being mindful to allow for a state of permissive hypotension.
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