He is also the innovation lead for the australian centre for health innovation at alfred health, a clinical adjunct associate professor at monash university, and the chair of the australian and new zealand intensive care society anzics education committee he is a cofounder of the australia and new zealand. The mortality in the hypothermia group was significantly higher than in normotherm patients or 3. Hypothermia can occur secondary to blood loss, regardless. Its important to appreciate the interplay between these three derangements, anticipate problems, and intervene quickly. Analysis of the leading causes of death in trauma patients reveals that hemorrhage is one of the most common and preventable etiologies in the acute period 1. External factors following trauma and iatrogenic intervention influence blood coagulation and particularly clot formation. Thought wed talk about some trauma stuff, specifically the resuscitation of the critically ill hemorrhagic shock patient. The lethal triad is a form of vicious cycle, which unless broken will result in death. Hypothermia, acidaemia and coagulopathy in trauma is associated with significant mortality. The aim of this article is to provide an overview of a new approach to managing major trauma known as damage control resuscitation, which is applicable to trauma casualties most at risk of traumatic coagulopathy and death, and aims to address all aspects of the lethal triad immediately on receiving the injured patient. Rather than resulting from tissue trauma, or traumatic brain injury alone, this is. Managing the trauma patient presenting with the lethal triad. Lessons in transport the lethal triad taming the sru.
The key terms used to search for evidence were trauma, injury, damage control surgery, spinal fixation, criticalintensive care and nurse. Acidosis coagulopathy hypothermia acidosis shock state tissue hypoperfusion and hypoxia physiologic and proinflammatory disruption resulting coagulopathy hypothermia mortality is increased in trauma patients with temperatures below 32c lethal triad in order to understand the complexities of the resuscitation in a bleeding trauma patient, we must become familiar with the lethal triad. With the organization of trauma systems, the development of trauma centers, the application of standardized methods of resuscitation, and improvements in modern blood banking. Hemorrhage is responsible for 30 to 40% of all traumarelated mortality. There is much to discuss, so this will be a multiepisode affair. List the individual components of the lethal triad of trauma. Therefore, appropriate initial fluid resuscitation for bleeding is crucial to avoid preventable traumarelated death. Current management of coagulopathyrelated bleeding is based on blood component replacement therapy. The interplay between hypothermia, acidosis and progressive coagulopathy, referred to as the lethal triad, often results in exsanguination.
The lethal triad in trauma acidosis, hypothermia, and coagulopathy defines much of what i do in the icu and cardiothoracic ors. To successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the lethal triad of trauma. Among adult trauma patients, 94% of hemorrhagerelated deaths occur within 24 h and approximately 60% of these deaths within 3 h of hospital admission. Nursing challenges with a severely injured patient in. It is important that orthopaedic trauma practitioners have the knowledge and skills to provide care for the injured patient that takes into account the physiological impact of trauma so that they can deliver best evidence based care for their patients.
A lethal triad of coagulopathy, acidosis, and hypothermia must all be addressed to provide adequate trauma resuscitation. The lethal triad consists of coagulopathy, hypothermia, and acidosis. The lethal triad is the path the decompensating patient follows on the progression towards shock and death. Recent advances of hemorrhage management in severe trauma. Learn simple interventions ems providers can perform to help prevent or slow the rapid progression of the lethal triad. A common cause of death in patients with traumatic injuries is what gerecht terms the lethal triad of hypothermia, acidosis, and. Lessons in transport the lethal triad december 02, 20 ryan gerecht, md.
How do external factors contribute to the hypocoagulative. Understand the pathophysiology that makes the lethal triad a deadly selfpropogating cycle in critically ill trauma patients. Although hypothermia reduces intracranial hypertension, a randomized trial in the new england journal of medicine found that hypothermia did not improve functional recovery as compared with standard care alone. Understanding of these mechanisms is helping develop the current management strategies in trauma shock involving haemostatic resuscitation. Peter burke discusses the methods his team uses to shave seconds off response time. The extensive medical training of troops on the ground, together with the placement of higher value medical assets at incident scenes, has facilitated the application of the abc paradigm. Trauma is one of the most common causes of mortality worldwide with a substantial percentage of deaths resulting secondary to haemorrhages, which are preventable and treatable when adequately managed. Indications for its application, however, are not well defined, and are currently based on the lethal triad used in physiologicallydecompensated trauma patients. Chris is an intensivist and ecmo specialist at the alfred icu in melbourne. Although trauma care has come a long way over the past 30 years, trauma is still one of the leading causes of death in any age group, writes ryan gerecht, md, cmte in the april, 2014 issue of the journal of emergency medical services. This article discusses the pathophysiology of atc and treatment strategies via the management of the lethal triad.
Bleeding causes acidosis, hypothermia, and coagulopathy. Ppt the trauma triad of death powerpoint presentation. Damage control resuscitation for patients with major trauma. Worldwide, trauma leads to millions of deaths and severe injuries each year. Ziglar, rn, msn director of trauma outreach university of north carolina hospitals trauma program chapel hill, nc 2 objectives. To determine if the lethal triad in multiple trauma patients is associated with higher mortality and injury score severity iss. The trauma triad of death 1 the trauma triad of death michele k. Putting a stop to exsanguination the lancet haematology.
Discuss the 3 leading complications in multisystem injured patients. Trauma resuscitation of the critically ill hemorrhagic. The treatment of coagulopathy and haemorrhage, in particular, has been. Atc can be exacerbated by hypothermia, acidosis and dilution coagulopathythe lethal triad of trauma. Hypothermia, acidosis, and coagulopathy constitute the lethal triad in trauma patients. The combination of acute coagulopathy, metabolic acidosis and hypothermia seen in trauma patients with significant haemorrhage has been termed the lethal triad. Unitek emt studies the importance of combatting traumas. Hypothermia as a predictor for mortality in trauma patients. In particular, three external factors in detail dilution via uncritical volume replacement, acidosis and hypothermia, in combination, referred to as the lethal triad, substantially aggravate the hypocoagulative state after trauma. An open airway and oxygen administration also can help avoid the cascade of events involved in the trauma triad of death.
The trauma triad of death is a medical term describing the combination of hypothermia, acidosis and coagulopathy. Anyway, he told me the second leading cause of death in a battlefield or was hypothermia, preceded only by exsanguination. We conducted a patient case study, with analysis of care using published evidence. However, there is a limit on the level of haemostasis that can be restored by replacement therapy. We report the care of a trauma patient with complex, conflicting injuries requiring management of the lethal triad. Injuries continue to be an important cause of morbidity and mortality worldwide, with haemorrhagic shock from blood loss being a critical cause of death in severely injured patients. Coagulopathy and blood component transfusion in trauma. Request pdf on apr 1, 2014, ryan gerecht and others published the lethal triad. The coagulopathy associated with haemorrhagic shock, which complicates major trauma, is a common scenario and a difficult challenge. This is one of my favorite podcasts on the lethal triad and i have shared it with dozens in the past. This report will focus on the role of hypothermia a third of the lethal triad in trauma, examining literature to assess how prehospital temperature control can impact on the trauma patient. Prevent the lethal triad hypothermia, coagulopathy, acidosis temperature 37 degrees. The staged laparotomy in the operative management of emergency general surgery egs patients is an extension of trauma surgeons operating on this population.
Lethal triad had been implicated in not only killing our trauma and shock patients early, but contributes to the third peak or delayed deaths by sepsis, multiple organ dysfunction, dic, and ards. The triad is one of the most important concepts of trauma and shock in general management and our understanding of it and two of its components impact on binding of o2 to hemaglobin, gives us more critical thinking tools when things are not going right. Describe historical events leading to improved trauma care. In total, 722 trauma patients were included, of which 300 patients were hypothermic. Neck trauma manage this in accordance with local protocols.
150 989 797 1456 754 627 1011 1209 1435 857 891 237 219 1153 1192 712 1527 1060 300 1034 1066 833 1370 1156 223 1365 790 9 43 393 1438 1396 652 1089 436 930 1097 1474 771 1439 931 325 290 863 244 193