EVIDENCE BASED PRACTICE

Evidence Based Practice

Evidence Based Practice

Introduction

Despite trauma and trauma haemorrhage management being the subject of numerous research studies it remains the leading cause of morbidity and mortality in the under 35 year age group (Office for National Statistics, 2006). Despite the abundance of research promoting best practice in major haemorrhage, the evidence continually shows poor outcome with mortality reaching up to 50 percent. Of this group a majority of patients will require a massive blood transfusion or have developed significant coagulopathy, a defective clotting mechanism causing profuse bleeding (Holcomb and et. al, 2011). Fluid resuscitation is a critical component in the management of hemorrhagic shock in trauma. Recently, significant advancement has been made in our understanding and approach to this vital therapy. Traditional large volume fluid therapy is being replaced by a more conservative restricted volume approach purporting to improve survival rates in trauma patients presenting with hemorrhagic shock.

The leading cause of death is predominantly caused by hypovolaemic shock secondary to blood loss. The main objective of trauma care is to minimise circulatory failure with a planned fluid replacement regimen in order to prevent organ and tissue death. However, in most instances due to the extent of injuries and tissue damage, optimum resuscitation can be ineffective and irreversible.

However, Jackson and Nolan (2009) state that by sustaining a blood pressure compatible with maintaining organ perfusion (90 mmHg systolic /60 mmHg diastolic), can potentially improve patient outcome and survival rates. Jansen et al (2011) suggests that overall massive haemorrhage management requires the 'lethal triad' to be the primary focus. This triad comprises of, coagulopathy, systemic acidosis and hypothermia and can play vital roles in determining the survival of the patient. With these in mind it enables the critical care providers to undertake damage control resuscitation. The integrated permissive hypotension, haemostatic resuscitation, and damage control surgery n the pre-hospital environment that addresses this lethal triad is initiated through the use of aggressive haemostatic techniques, for example the use of combat application tourniquets, haemostatic agents such as Combat Gauze, Celox, WoundStat and pressure bandages (Hodgetts et al, 2006), temperature monitoring and control to prevent hypothermia, and variable controlled amounts of intravenous fluids to maintain permissive hypotension (Greaves et al, 2002). All of these measures are being continually reviewed and adapted clinically.

Discussion

The PICO question here focuses on the area of permissive hypotension.

Permissive hypotension involves the variable administration of intravenous fluid to maintain a blood pressure which enables a radial pulse to be continually palpated (Sumann, Günther, et al., 2002). Over administration of intravenous fluid immediately following massive haemorrhage creates delayed coagulation by causing an increase in blood pressure and dilution of clotting factors such as platelet aggregation. Nonetheless, the early and rapid administration of intravenous fluids has been an integral part of trauma resuscitation for numerous years and despite that considerable literature and research regarding permissive hypotension, copious fluid administration remains a fundamental part of pre-hospital care through out the world (Beeson, 2013). Shock occurs when circulatory abnormality results in inadequate tissue perfusion ...