, Volume 471, Issue 12, pp 3961-3973
Date: 27 Jun 2013

The Initial Trauma Center Fluid Management of Penetrating Injury: A Systematic Review

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Abstract

Background

Damage-control resuscitation is the prevailing trauma resuscitation technique that emphasizes early and aggressive transfusion with balanced ratios of red blood cells (RBCs), plasma (FFP), and platelets (Plt) while minimizing crystalloid resuscitation, which is a departure from Advanced Trauma Life Support (ATLS) guidelines. It is unclear whether the newer approach is superior to the approach recommended by ATLS.

Questions/purposes

With these recent changes pervading resuscitation protocols, we performed a systematic review to determine if the shift in trauma resuscitation from ATLS guidelines to damage control resuscitation has improved mortality in patients with penetrating injuries.

Methods

A systematic search of PubMed, the Cochrane Library, and the Current Controlled Trials Register was performed for studies comparing mortality in massively transfused penetrating trauma patients receiving either balanced ratios of blood transfusion per damage control resuscitation tenets or undergoing an alternate blood volume resuscitation strategy. Studies were deemed appropriate for inclusion if they had a Newcastle-Ottawa Scale score of 6 or greater as well as at least 30% penetrating trauma. Twenty studies that reported on a total of 12,154 patients were included.

Results

Transfusion ratios varied widely, with 1:1 and 1:2 ratios of FFP:RBC most often defined as high ratios for purposes of comparison with other low ratio groups. Fourteen of 20 studies found significantly lower 30-day mortality when higher transfusion ratios of FFP, RBC, and/or Plt were used; six of 20 studies found mortality to be similar between higher and lower transfusion ratios.

Conclusions

Patients with penetrating injuries who require massive transfusion should be transfused early using balanced ratios of RBC, FFP, and Plt. Randomized, controlled trials are needed to determine optimal ratios for transfusion.

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.